Preliminary 12/10/07. ICD-10-PCS Reference Manual

Transcription

1 Preliminary 12/10/07 ICD-10-PCS Reference Manual

2 12/10/07 Preliminary ii ICD-10-PCS Reference Manual

3 Preliminary 12/10/07 THE INTERNATIONAL CLASSIFICATION OF DISEASES Tenth Revision Procedure Coding System (ICD-10-PCS) was developed with the support of the Centers for Medicare and Medicaid Services, under contract Nos , , , and HHSM C to 3M Health Information Systems. Rhonda R. Butler, CCS, CCS-P Robert L. Mullin, M.D. Thelma M. Grant, MBA, RHIA Richard F. Averill, M.S. Barbara A. Steinbeck, RHIT The opinions expressed are solely those of the authors, and do not necessarily represent those of the Centers for Medicare and Medicaid Services. iii

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5 Preliminary 12/10/07 Preface THE INTERNATIONAL CLASSIFICATION OF DISEASES Tenth Revision Procedure Coding System (ICD-10-PCS) is a new system for coding inpatient procedures, developed for the Centers for Medicare and Medicaid Services (CMS). This manual is written as a general introduction for data managers, payers, administrators, and medical record coders. For readers who do not need a detailed understanding of ICD-10-PCS but would like a general introduction, the material in chapter 1 and the appendices is recommended. Manual organization Chapter 1 Chapter 2 The manual is organized into the following chapters and appendices. A glossary also provides a list of terms introduced in the manual. Overview. Includes a general introduction to ICD-10-PCS, a brief history of its development, and a presentation of the code structure, organization, and characteristics. The first part of the overview contains basic information; the second and third parts discuss structure, characteristics, and applications in more detail. Procedures in the Medical and Surgical section. Provides reference material for each root operation in the MEDICAL AND SURGICAL section (0), with the full definition, additional explanation as needed, a code example, and coding exercises for each root operation. Preface v

6 12/10/07 Preliminary Chapter 3 Chapter 4 Appendix A Appendix B Procedures in the Medical and Surgical-related sections. Provides reference material for each of the Medical and Surgical-related sections (1 9), with definitions, additional explanation as needed, a code example, and coding exercises for each section. Procedures in the ancillary sections. Provides reference material for each of the ancillary sections (B D, F H), with definitions, additional explanation as needed, a code example, and coding exercises for each section. ICD-10-PCS definitions. Tables listing the full definitions of all root operations and approaches in the MEDICAL AND SURGICAL section. ICD-10-PCS draft coding guidelines. Contains draft guidelines for coding procedures with ICD-10-PCS. Conventions used Small capital letters Root operation boxes This manual uses several conventions throughout, as described below. Small capital letters are used to distinguish words that define code components, as in the root operation TRANSPLANTATION. Root operation boxes are used to present the full definition of root operations in the MEDICAL AND SURGICAL section, including explanation and examples. A root operation box is shown below. Root operation boxes are used in chapter 2. Drainage Definition Taking or letting out fluids and/or gases from a body part 9 Explanation The fluids or gases may be normal or abnormal Examples Incision and drainage, thoracentesis Table excerpts Table excerpts present a single code in the ICD-10-PCS Table format, identifying all components of the code. Text descriptions are truncated as needed to fit the compressed format, as in the example below. Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND SURGICAL RESPIRATORY EXCISION LOWER LOBE BRONCHUS, RT OPEN NO DEVICE DIAGNOSTIC 0 B B 6 0 Z X vi ICD-10-PCS Reference Manual

7 Preliminary 12/10/07 Root operation groups This table is used only in chapter 2 to organize root operations in the MEDICAL AND SURGICAL section, highlighting distinguishing features.. Root operation Procedure Objective Procedure Site Example Drainage Taking/letting out fluids/gases Within a body part I&D of perinephric cyst Extirpation Taking/cutting out solid matter Within a body part Taking out a kidney stone Fragmentation Breaking solid matter into pieces without removal Within a body part Lithotripsy of kidney stone Preface vii

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9 Preliminary 12/10/07 Contents Chapter 1 ICD-10-PCS overview 1.3 What is ICD-10-PCS? 1.4 History of ICD-10-PCS 1.4 ICD-9-CM Volume 3 compared with ICD-10-PCS 1.4 ICD-10-PCS code structure 1.6 Characters 1.6 Values 1.6 Code structure: Medical and Surgical section 1.7 Character 1: Section 1.7 Character 2: Body system 1.7 Character 3: Root operation 1.8 Character 4: Body part 1.8 Character 5: Approach 1.8 Character 6: Device 1.9 Character 7: 1.9 ICD-10-PCS system organization 1.11 Medical and Surgical section 1.11 Medical and Surgical-related sections 1.11 Ancillary sections 1.12 Tables 1.13 Index 1.15 List of Codes 1.17 ICD-10-PCS design 1.18 Multiaxial structure 1.18 Completeness 1.19 Expandability 1.21 Contents ix

10 12/10/07 Preliminary ICD-10-PCS additional characteristics 1.23 Standardized terminology 1.23 Standardized level of specificity 1.24 Diagnosis information excluded 1.25 NOS code options restricted 1.25 Limited NEC code options 1.25 ICD-10-PCS applications 1.26 Optimal search capability 1.26 Consistent characters and values 1.27 Code readability 1.28 Chapter 2 Procedures in the Medical and Surgical section 2.5 Root operation groups 2.6 Root operations that take out some or all of a body part 2.8 Excision Root operation B 2.9 Resection Root operation T 2.11 Detachment Root operation Destruction Root operation Extraction Root operation D 2.18 Root operations that take out solids/fluids/gases from a body part 2.20 Drainage Root operation Extirpation Root operation C 2.23 Fragmentation Root operation F 2.25 Root operations involving cutting or separation only 2.27 Division Root operation Release Root operation N 2.29 Root operations that put in/put back or move some/all of a body part 2.31 Transplantation Root operation Y 2.32 Reattachment Root operation M 2.34 Transfer Root operation X 2.36 Reposition Root operation S 2.38 Root operations that alter the diameter/route of a tubular body part 2.40 Restriction Root operation V 2.41 Occlusion Root operation L 2.43 Dilation Root operation Bypass Root operation Root operations that always involve a device 2.49 Insertion Root operation H 2.50 Replacement Root operation R 2.52 Change Root operation x ICD-10-PCS Reference Manual

11 Preliminary 12/10/07 Removal Root operation P 2.55 Revision Root operation W 2.57 Root operations involving examination only 2.58 Inspection Root operation J 2.59 Map Root operation K 2.60 Root operations that define other repairs 2.61 Control Root operation Repair Root operation Q 2.63 Root operations that define other objectives 2.65 Fusion Root operation G 2.66 Alteration Root operation Creation Root operation Chapter 3 Procedures in the Medical and Surgical-related sections 3.3 List of Medical and Surgical-related sections of ICD-10-PCS 3.4 Obstetrics Section Root operations 3.5 Placement Section Root operations 3.7 Administration Section Root operations 3.10 Measurement and Monitoring Section Root operations 3.12 Extracorporeal Assistance and Performance Section Root operations 3.14 Extracorporeal Therapies Section Root operations 3.16 Osteopathic Section Other Procedures Section Chiropractic Section Chapter 4 Procedures in the ancillary sections 4.3 List of ancillary sections in ICD-10-PCS 4.4 Imaging Section B 4.5 Root types 4.5 Contents xi

12 12/10/07 Preliminary Nuclear Medicine Section C 4.8 Root types 4.8 Radiation Oncology Section D 4.11 Root type 4.11 Physical Rehabilitation and Diagnostic Audiology Section F 4.13 Root types 4.13 Mental Health Section G 4.17 Root Type 4.17 Substance Abuse Treatment Section H 4.19 Root Types 4.19 Appendix A ICD-10-PCS definitions A.3 Root operations A.4 Approaches A.8 Appendix B ICD-10-PCS draft coding guidelines B.3 A. General B.3 B. Medical and Surgical section (section 0) B.4 Body system guidelines B.4 Root operation guidelines B.4 Body part guidelines B.7 Approach guidelines B.9 Device guidelines B.10 C. Other medical and surgical-related sections (sections 1 9) B.11 Index Alphabetical index I.1 xii ICD-10-PCS Reference Manual

13 Tables Table Title and page 1 1 Comparison of ICD-9-CM and ICD-10-PCS Introductory table of values for the Medical and Surgical section Urinary body system (characters 3 7) Comparison of CABG procedure codes 1.20 Tables xiii

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15 Preliminary 12/10/07 Chapter 1 1ICD-10-PCS overview

16 12/10/07 Preliminary Contents ICD-10-PCS overview 1.3 What is ICD-10-PCS? 1.4 History of ICD-10-PCS 1.4 ICD-9-CM Volume 3 compared with ICD-10-PCS 1.4 ICD-10-PCS code structure 1.6 Characters 1.6 Values 1.6 Code structure: Medical and Surgical section 1.7 Character 1: Section 1.7 Character 2: Body system 1.7 Character 3: Root operation 1.8 Character 4: Body part 1.8 Character 5: Approach 1.8 Character 6: Device 1.9 Character 7: 1.9 ICD-10-PCS system organization 1.11 Medical and Surgical section 1.11 Medical and Surgical-related sections 1.11 Ancillary sections 1.12 Tables 1.13 Index 1.15 List of Codes 1.17 ICD-10-PCS design 1.18 Multiaxial structure 1.18 Completeness 1.19 Expandability 1.21 ICD-10-PCS additional characteristics 1.23 Standardized terminology 1.23 Standardized level of specificity 1.24 Diagnosis information excluded 1.25 NOS code options restricted 1.25 Limited NEC code options 1.25 ICD-10-PCS applications 1.26 Optimal search capability 1.26 Consistent characters and values 1.27 Code readability ICD-10-PCS Reference Manual

17 Preliminary 12/10/07 Chapter 1 ICD-10-PCS overview THE INTERNATIONAL CLASSIFICATION OF DISEASES Tenth Revision Procedure Coding System (ICD-10-PCS) was created to accompany the World Health Organization s (WHO) ICD-10 diagnosis classification. The new procedure coding system was developed to replace ICD-9-CM procedure codes for reporting inpatient procedures. Unlike the ICD-9-CM classification, ICD-10-PCS was designed to enable each code to have a standard structure and be very descriptive, and yet flexible enough to accommodate future needs. Information about the structure, organization, and application of ICD-10-PCS codes, along with reference material for coding with ICD-10-PCS, is provided in this manual. This chapter contains the following parts: What is ICD-10-PCS? ICD-10-PCS code structure ICD-10-PCS system organization ICD-10-PCS design ICD-10-PCS additional characteristics ICD-10-PCS applications More specific information on coding with ICD-10-PCS is found in chapters 2 4 of this manual. ICD-10-PCS overview 1.3

18 12/10/07 Preliminary What is ICD-10-PCS? ICD-10-PCS is a procedure coding system that will be used to collect data, determine payment, and support the electronic health record for all inpatient procedures performed in the United States. History of ICD-10-PCS The World Health Organization has maintained the International Classification of Diseases (ICD) for recording cause of death since It has updated the ICD periodically to reflect new discoveries in epidemiology and changes in medical understanding of disease. The International Classification of Diseases Tenth Revision (ICD-10), published in 1992, is the latest revision of the ICD. The WHO authorized the National Center for Health Statistics (NCHS) to develop a clinical modification of ICD-10 for use in the United States. This version of ICD-10 is called ICD-10-CM. ICD-10-CM is intended to replace the previous U.S. clinical modification, ICD-9-CM, that has been in use since ICD-9-CM contains a procedure classification; ICD-10-CM does not. The Centers for Medicare and Medicaid Services, the agency responsible for maintaining the inpatient procedure code set in the U.S., contracted with 3M Health Information Systems in 1993 to design and then develop a procedure classification system to replace Volume 3 of ICD-9-CM. ICD-10-PCS is the result. ICD-10-PCS was initially released in It has been updated annually since that time. ICD-9-CM Volume 3 compared with ICD-10-PCS With ICD-10 implementation, the U.S. clinical modification of the ICD will not include a procedure classification based on the same principles of organization as the diagnosis classification. Instead, a separate procedure coding system has been developed to meet the rigorous and varied demands that are made of coded data in the healthcare industry. This represents a significant step toward building a health information infrastructure that functions optimally in the electronic age. The following table highlights basic differences between ICD-9-CM Volume 3 and ICD-10-PCS. 1.4 ICD-10-PCS Reference Manual

19 Preliminary 12/10/07 What is ICD-10-PCS? Table 1 1. Comparison of ICD-9-CM and ICD-10-PCS ICD-9-CM Volume 3 Follows ICD structure (designed for diagnosis coding) Codes available as a fixed/finite set in list form Codes are numeric Codes are 3 4 digits long ICD-10-PCS Designed/developed to meet healthcare needs for a procedure code system Codes constructed from flexible code components (values) using tables Codes are alphanumeric All codes are seven characters long ICD-10-PCS overview 1.5

20 12/10/07 Preliminary ICD-10-PCS code structure Undergirding ICD-10-PCS is a logical, consistent structure that informs the system as a whole, down to the level of a single code. This means that the process of constructing codes in ICD-10-PCS is also logical and consistent: individual letters and numbers, called values, are selected in sequence to occupy the seven spaces of the code, called characters. Characters All codes in ICD-10-PCS are seven characters long. Each character in the seven-character code represents an aspect of the procedure, as shown in the following diagram of characters from the main section of ICD-10-PCS, called MEDICAL AND SURGICAL. Section Root operation Approach Characters: Body system Body part Device An ICD-10-PCS code is best understood as the result of a process rather than as an isolated, fixed quantity. The process consists of assigning values from among the valid choices for that part of the system, according to the rules governing the construction of codes. Values One of 34 possible values can be assigned to each character in a code: the numbers 0 9 and the alphabet (except I and O, because they are easily confused with the numbers 1 and 0). A finished code looks like the example below Z4 This code is derived by choosing a specific value for each of the seven characters. Based on details about the procedure performed, values for each character specifying the section, body system, root operation, body part, approach, device, and qualifier are assigned. Because the definition of each character is a function of its physical position in the code, the same value placed in a differ- 1.6 ICD-10-PCS Reference Manual

21 Preliminary 12/10/07 ICD-10-PCS code structure ent position in the code means something different. The value 0 in the first character means something different than 0 in the second character, or 0 in the third character, and so on. Code structure: Medical and Surgical section The following pages define each character using the code 0LB50ZZ, Excision of right lower arm and wrist tendon, open approach as an example. This example comes from the MEDICAL AND SURGICAL section of ICD-10-PCS. Character 1: Section The first character in the code determines the broad procedure category, or section, where the code is found. In this example, the section is MEDICAL AND SURGICAL. 0 is the value that represents MEDICAL AND SURGICAL in the first character. For definitions of characters used in the Medical and Surgical section, please refer to the Glossary. The sample code looks like this so far: Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND SURGICAL 0 Character 2: Body system The second character defines the body system the general physiological system or anatomical region involved. Examples of body systems include LOWER ARTERIES, CENTRAL NERVOUS SYSTEM, and RESPIRATORY SYSTEM. In this example, the body system is TENDONS, represented by the value L. Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND TENDONS SURGICAL 0 L ICD-10-PCS overview 1.7

22 ICD-10-PCS code structure 12/10/07 Preliminary Character 3: Root operation The third character defines the root operation, or the objective of the procedure. Some examples of root operations are BYPASS, DRAINAGE, and REATTACHMENT. In the sample code below, the root operation is EXCISION. When used in the third character of the code, the value B represents EXCISION. Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND SURGICAL TENDONS EXCISION 0 L B For the complete list of root operations and their definitions, please refer to appendix A. Character 4: Body part The fourth character defines the body part, or specific anatomical site where the procedure was performed. The body system (second character) provides only a general indication of the procedure site. The the body part and body system values together provide a precise description of the procedure site. Examples of body parts are KIDNEY, TONSILS, and THYMUS. In this example, the body part value is 5, LOWER ARM AND WRIST, RIGHT. When the second character is L, the value 5 when used in the fourth character of the code represents the right lower arm and wrist tendon. Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND SURGICAL TENDONS EXCISION LOWER ARM AND WRIST, RIGHT 0 L B 5 Character 5: Approach The fifth character defines the approach, or the technique used to reach the procedure site. Eight different approach values are used in the MEDICAL AND SURGICAL section to define the approach. Examples of approaches include OPEN and PERCUTANEOUS ENDOSCOPIC. In the sample code below, the approach is OPEN and is represented by the value ICD-10-PCS Reference Manual

23 Preliminary 12/10/07 ICD-10-PCS code structure Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND SURGICAL TENDONS EXCISION LOWER ARM AND WRIST, RIGHT OPEN 0 L B 5 0 For the complete list of approaches and their definitions, please refer to appendix A. Character 6: Device Depending on the procedure performed, there may or may not be a device left in place at the end of the procedure. The sixth character defines the device. Device values fall into four basic categories: Grafts and Prostheses Implants Simple or Mechanical Appliances Electronic Appliances In this example, there is no device used in the procedure. The value Z is used to represent NO DEVICE, as shown below. Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND SURGICAL TENDONS EXCISION LOWER ARM AND WRIST, RIGHT OPEN NO DEVICE 0 L B 5 0 Z Character 7: The seventh character defines a qualifier for the code. A qualifier specifies an additional attribute of the procedure, if applicable. Examples of qualifiers include DIAGNOSTIC and STEREOTACTIC. choices vary depending on the previous values selected. In this example, there is no specific qualifier applicable to this procedure, so the value is NO QUALIFIER, represented by the letter Z. ICD-10-PCS overview 1.9

24 ICD-10-PCS code structure 12/10/07 Preliminary Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND SURGICAL TENDONS EXCISION LOWER ARM AND WRIST, RIGHT OPEN NO DEVICE NO QUALIFIER 0 L B 5 0 Z Z 0LB50ZZ is the complete specification of the procedure Excision of right lower arm and wrist tendon, open approach ICD-10-PCS Reference Manual

25 Preliminary 12/10/07 ICD-10-PCS system organization ICD-10-PCS is composed of 16 sections, represented by the numbers 0 9 and the letters B D and F H. The broad procedure categories contained in these sections range from surgical procedures to substance abuse treatment. Medical and Surgical section The first section, MEDICAL AND SURGICAL, contains the great majority of procedures typically reported in an inpatient setting. As shown in the previous section discussing ICD-10-PCS code structure, all procedure codes in the MEDICAL AND SURGICAL section begin with the section value 0. Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND SURGICAL TENDONS EXCISION LOWER ARM AND WRIST, RIGHT OPEN NO DEVICE NO QUALIFIER 0 L B 5 0 Z Z More complete information on coding procedures in the Medical and Surgical section is found in chapter 2 of this manual. Medical and Surgical-related sections Sections 1 9 of ICD-10-PCS comprise the Medical and Surgical-related sections. These sections include obstetrical procedures, administration of substances, measurement and monitoring of body functions, and extracorporeal therapies, as listed in the table below. Section value Description 1 Obstetrics 2 Placement 3 Administration 4 Measurement and Monitoring 5 Extracorporeal Assistance and Performance 6 Extracorporeal Therapies 7 Osteopathic 8 Other Procedures 9 Chiropractic ICD-10-PCS overview 1.11

26 ICD-10-PCS system organization 12/10/07 Preliminary In sections 1 and 2, all seven characters define the same aspects of the procedure as in the MEDICAL AND SURGICAL section. Codes in sections 3 9 are structured for the most part like their counterparts in the MEDICAL AND SURGICAL section, with a few exceptions. For example, in sections 5 and 6, the fifth character is defined as duration instead of approach, as in this code for intra-aortic balloon pump (IABP): Character 1 Section EXTRACORP. ASSIST. AND PERFORMANCE Character 2 PHYSIOLOGICAL SYSTEMS Character 3 Root Operation Character 4 Character 5 Duration Character 6 Function Character 7 ASSISTANCE CARDIAC CONTINUOUS OUTPUT BALLOON PUMP 5 A Additional differences include these uses of the sixth character: Section 3 defines the sixth character as substance. Sections 4 and 5 define the sixth character as function. Sections 7 9 define the sixth character as method. More complete information on coding procedures in the Medical and Surgical-related sections is found in chapter 3 of this manual. Ancillary sections Sections B D and F H comprise the ancillary sections of ICD-10-PCS. These six sections include imaging procedures, nuclear medicine, and substance abuse treatment, as listed in the following table. Section value B C D F G H Description Imaging Nuclear Medicine Radiation Oncology Physical Rehabilitation and Diagnostic Audiology Mental Health Substance Abuse Treatment The definitions of some characters in the ancillary sections differs from that seen in previous sections. In the IMAGING section, the third character is defined as type, and the fifth and sixth characters define contrast and contrast/qualifier respectively, as in the CT scan example below ICD-10-PCS Reference Manual

27 Preliminary 12/10/07 ICD-10-PCS system organization Character 1 Section Character 2 Character 3 Type Character 4 Body Part Character 5 Contrast Character 6 Character 7 IMAGING CENTRAL COMPUTERIZED BRAIN HIGH OSMOLAR UNENHANCED NONE NERVOUS TOMOGRAPHY AND ENHANCED B Z Additional differences include: Section C defines the fifth character as radionuclide. Section D defines the fifth character as modality qualifier and the sixth character as isotope. Section F defines the tdefines the fifth character as type qualifier and the sixth character as equipment. Sections G and H define the third character as a type qualifier. More complete information on coding procedures in the ancillary sections is found in chapter 4 of this manual. Tables The complete ICD-10-PCS is presented in three parts: the Tables, the Index, and the List of Codes. The Tables are organized in a series, beginning with section 0, MEDICAL AND SURGICAL, and body system 0, CENTRAL NERVOUS, and proceeding in numerical order. Sections 0 9 are followed by sections B D and F H. The same convention is followed within each table for the second through the seventh characters numeric values in order first, followed by alphabetical values in order. The following examples use the MEDICAL AND SURGICAL section to describe the organization and format of the ICD-10-PCS Tables. The MEDICAL AND SURGICAL section (first character 0) is organized by its 31 body system values. Each body system subdivision in the MEDICAL AND SURGICAL section contains an introductory table that lists the possible values for the remaining characters, given that body system. The following example shows the introductory table for the URINARY system. ICD-10-PCS overview 1.13

28 ICD-10-PCS system organization 12/10/07 Preliminary Table 1 2. Introductory table of values for the Medical and Surgical section Urinary body system (characters 3 7) Operation Character 3 Body Part Character 4 Approach Character 5 Device Character 6 Character 7 1 Bypass 0 Kidney, Right 0 Open 0 Drainage Device 0 Allogeneic 2 Change 1 Kidney, Left 2 Open Endoscopic 1 Radioactive Element 5 Destruction 2 Kidneys, Bilateral 3 Percutaneous 2 Monitoring Device 7 Dilation 3 Kidney Pelvis, Right 4 Percutaneous Endoscopic 8 Division 4 Kidney Pelvis, Left 7 Via Natural or Artificial Opening 9 Drainage 5 Kidney 8 Via Natural or Artificial Opening Endoscopic 1 Syngeneic 2 Zooplastic 3 Infusion Device 3 Kidney Pelvis, Right 7 Autologous Tissue Substitute C Extraluminal Device B Excision 6 Ureter, Right X External D Intraluminal Device C Extirpation 7 Ureter, Left J Synthetic Substitute F Fragmentation 8 Ureters, Bilateral K Nonautologous Tissue Substitute H Insertion 9 Ureter L Artificial Sphincter 4 Kidney Pelvis, Left 6 Ureter, Right 7 Ureter, Left 8 Colon 9 Colocutaneous A Ileum J Inspection B Bladder M Electrode B Bladder L Occlusion C Bladder Neck Y Other Device C Ileocutaneous M Reattachment D Urethra Z No Device D Cutaneous N Release P Removal Q Repair R Replacement S Reposition T Resection V Restriction W Revision Y Transplantation X Diagnostic Z No Following the introductory table are the root operation tables. These tables provide the valid choices of values available to construct a code ICD-10-PCS Reference Manual

29 Preliminary 12/10/07 ICD-10-PCS system organization The root operation tables consist of four columns and a varying number of rows, as in the following example of the root operation BYPASS, in the CENTRAL NERVOUS body system. Section Body system Root operation 0: MEDICAL AND SURGICAL 0: CENTRAL NERVOUS 1: BYPASS: Altering the route of passage of the contents of a tubular body part Body Part Character 4 Approach Character 5 Device Character 6 6 Cerebral Ventricle 0 Open 7 Autologous Tissue Substitute J Synthetic Substitute K Nonautologous Tissue Substitute U Spinal Canal 0 Open 7 Autologous Tissue Substitute J Synthetic Substitute K Nonautologous Tissue Substitute Character 7 0 Nasopharynx 1 Mastoid Sinus 2 Atrium 3 Blood Vessel 4 Pleural Cavity 5 Intestine 6 Peritoneal Cavity 7 Urinary Tract 8 Bone Marrow B Cerebral Cisterns 4 Pleural Cavity 6 Peritoneal Cavity 7 Urinary Tract 9 Fallopian Tube The values for characters 1 3 are provided at the top of each table. Four columns contain the applicable values for characters 4 7, given the values in characters 1 3. A table may be separated into rows to specify the valid choices of values in characters 4 7. A built using values from more than one row of a table is not a valid code. For the complete list of ICD-10-PCS draft coding guidelines, please refer to appendix B. Index The ICD-10-PCS Index can be used to access the Tables. The Index mirrors the structure of the Tables, so it follows a consistent pattern of organization and use of hierarchies. The Index is organized as an alphabetic lookup. Two types of main terms are listed in the Index: Based on the value of the third character Common procedure terms ICD-10-PCS overview 1.15

30 ICD-10-PCS system organization 12/10/07 Preliminary Main terms For the MEDICAL AND SURGICAL and related sections, the root operation values are used as main terms in the Index. In other sections, the values representing the general type of procedure performed, such as nuclear medicine or imaging type, are listed as main terms. For the MEDICAL AND SURGICAL and related sections, values such as EXCISION, BYPASS, and TRANSPLANTATION are included as main terms in the Index. The applicable body system entries are listed beneath the main term, and refer to a specific table. For the ancillary sections, values such as FLUOROSCOPY and POSITRON EMISSION TOMOGRAPHY are listed as main terms. In the example below, the index entry Bypass refers to the MEDICAL AND SURGICAL section tables for all applicable body systems, including ANATOMICAL REGIONS and CENTRAL NERVOUS SYSTEM. Bypass by Anatomical Regions 0W1... Central Nervous System The body system listings may be followed by entries for specific body parts, as in the excerpt below. In the root operations CHANGE, INSERTION, REMOVAL, and REVISION, the device entries follow the body system listings. by Body Part Artery Aorta, Abdominal Aorta, Thoracic 021W... Axillary Brachial Common Carotid Common procedure terms The second type of term listed in the Index uses procedure names, such as appendectomy or fundoplication. These entries are listed as main terms, and refer to a table or tables from which a valid code can be constructed, as shown in the following example. Cholecystectomy see Excision, Hepatobiliary System & Pancreas 0FB... see Resection, Hepatobiliary System & Pancreas 0FT ICD-10-PCS Reference Manual

31 Preliminary 12/10/07 ICD-10-PCS system organization List of Codes The ICD-10-PCS List of Codes is a resource that displays all valid codes in alphanumeric order. Each entry begins with the seven-character code, followed by the full text description. The code descriptions are generated using rules that produce standardized, complete, and easy-to-read code descriptions. ICD-10-PCS overview 1.17

32 12/10/07 Preliminary ICD-10-PCS design ICD-10-PCS is fundamentally different from ICD-9-CM in its structure, organization, and capabilities. It was designed and developed to adhere to recommendations made by the National Committee on Vital and Health Statistics (NCVHS). It also incorporates input from a wide range of organizations, individual physicians, healthcare professionals, and researchers. Several structural attributes were recommended for a new procedure coding system. These attributes include Multiaxial structure Completeness Expandability Multiaxial structure The key attribute that provides the framework for all other structural attributes is multiaxial code structure. Multiaxial code structure makes it possible for the ICD-10-PCS to be complete, expandable, and to provide a high degree of flexibility and functionality. As mentioned earlier, ICD-10-PCS codes are composed of seven characters. Each character represents a category of information that can be specified about the procedure performed. A character defines both the category of information and its physical position in the code. Section Root operation Approach Characters: Body system Body part Device A character s position can be understood as a semi-independent axis of classification that allows different specific values to be inserted into that space, and whose physical position remains stable. Within a defined code range, a character retains the general meaning that it confers on any value in that position. For example, the fifth character retains the general meaning approach in sections 0 4 and 7 9 of the system. Any 1.18 ICD-10-PCS Reference Manual

33 Preliminary 12/10/07 ICD-10-PCS design specific value in the fifth character will define a specific approach, such as OPEN. Each group of values for a character contains all of the valid choices in relation to the other characters of the code, giving the system completeness. In the fifth character, for example, each significantly distinct approach is assigned its own approach value and all applicable approach values are included to represent the possible versions of a procedure. Each group of values for a character can be added to as needed, giving the system expandability. If a significantly distinct approach is used to perform procedures, a new approach value can be added to the system. Each group of values is confined to its own character, giving ICD-10-PCS a stable, predictable readability across a wide range of codes. In sections 0 4 and 7 9 of the system, for example, the fifth character always represents the approach. ICD-10-PCS multiaxial structure houses its capacity for completeness, expandability, and flexibility, giving it a high degree of functionality for multiple uses. Completeness Completeness is considered a key structural attribute for a new procedure coding system. The specific recommendation for completeness includes these characteristics: A unique code is available for each significantly different procedure. Each code retains its unique definition. Codes are not reused. In Volume 3 of ICD-9-CM, procedures performed on many different body parts using different approaches or devices may be assigned to the same procedure code. In ICD-10-PCS, a unique code can be constructed for every significantly different procedure. Within each section, a character defines a consistent component of a code, and contains all applicable values for that character. The values define individual expressions (open, percutaneous) of the character s general meaning (approach) that are then used to construct unique procedure codes. Because all approaches by which a procedure is performed are assigned a separate approach value in the system, every procedure which uses a different approach will have its own unique code. This is true of the other characters as well. The same procedure performed on a different body part has its own unique ICD-10-PCS overview 1.19

34 ICD-10-PCS design 12/10/07 Preliminary code, the same procedure performed using a different device has its own unique code, and so on. Coronary bypass example In the case of the coronary artery bypass graft (CABG), ICD-9-CM contains a total of nine codes to describe different versions of the procedure. These codes specify the version based on one aspect of the procedure, and the aspect defined is not consistent for all nine codes. Four of the codes specify the number of coronary arteries bypassed, four specify the source of the new blood flow, and one is an unspecified choice. By contrast, ICD-10-PCS components can be combined to produce 34 unique codes defining all significantly different versions of the comparable CABG procedure. All 34 codes specify the same four aspects of the procedure: the number of coronary artery sites bypassed, the approach to the procedure site, the type of graft if used, and the origin of the bypass (source of the new blood flow). The differences are summarized in the table below. Table 1 3. Comparison of CABG procedure codes ICD-9-CM Volume 3 ICD-10-PCS Aortocoronary Bypass of One Coronary Artery (1 of 4) Single Internal Mammary- Coronary Artery Bypass (1 of 2) Abdominal-Coronary Artery Bypass (1 of 2) Aortocoronary Bypass for Heart Revascularization, Not Otherwise Specified (1 of 1) W Bypass Coronary Artery, One Site to Aorta with Autologous Venous Tissue, Open Approach(1 of 8) 02100Z8 Bypass Coronary Artery, One Site to Right Internal Mammary, Open Approach (1 of 16) 02100AF Bypass Coronary Artery, One Site to Abdominal Artery with Autologous Arterial Tissue, Open Approach (1 of 10) No Equivalent ICD-10-PCS codes all contain a minimum level of specificity Unique definitions Because ICD-10-PCS codes are constructed of individual values rather than lists of fixed codes and text descriptions, the unique, stable definition of a code in the system is retained. New values may be added to the system to represent a specific new approach or device or qualifier, but whole codes by design cannot be given new meanings and reused ICD-10-PCS Reference Manual

35 Preliminary 12/10/07 ICD-10-PCS design Expandability Expandability was also recommended as a key structural attribute. The specific recommendation for expandability includes these characteristics: Accommodate new procedures and technologies Add new codes without disrupting the existing structure ICD-10-PCS is designed to be easily updated as new codes are required for new procedures and new techniques. Changes to ICD-10-PCS can all be made within the existing structure, because whole codes are not added. Instead, one of two possible changes is made to the system: A new value for a character is added as needed to the system. An existing value for a character is added to a table(s) in the system. ICD-10-PCS update: PICVA An example of how the updating of ICD-10-PCS works can be seen in the coronary artery bypass procedure called Percutaneous in-situ coronary venous arterialization (PICVA). This procedure is no more invasive than a percutaneous coronary angioplasty, but achieves the benefits of a bypass procedure by placing a specialized stent into the diseased coronary artery, through its wall into the adjacent coronary vein, and diverting blood flow through the stent into the artery past the blockage. ICD-10-PCS was updated in 2004 to include an appropriate range of codes for the PICVA procedure (16 possible codes). This was accomplished simply by adding another row to the relevant table (see table 021, BYPASS, HEART AND GREAT VESSELS) containing two approach values for the non-invasive approach, two device values for the possible types of stent, and a single qualifier defining the coronary vein as the source of the new blood flow, as in the example below. 0: MEDICAL AND SURGICAL 2: HEART AND GREAT VESSELS 1: BYPASS: Altering the route of passage of the contents of a tubular body part Body Part Character 4 Approach Character 5 Device Character 6 Character 7 0 Coronary Artery, One Site 1 Coronary Artery, Two Sites 2 Coronary Artery, Three Sites 3 Coronary Artery, Four or More Sites 3 Percutaneous 4 Percutaneous Endoscopic 4 Drug-eluting Intraluminal Device D Intraluminal Device D Coronary Vein ICD-10-PCS overview 1.21

36 ICD-10-PCS design 12/10/07 Preliminary Structural integrity As shown in the previous example, ICD-10-PCS can be easily expanded without disrupting the structure of the system. In the PICVA example, one new value the qualifier value CORONARY VEIN was added to the system to effect this change. All other values in the new row are existing values used to create unique, new codes. This type of updating can be replicated anywhere in the system when a change is required. ICD-10-PCS allows unique new codes to be added to the system because values for the seven characters that make up a code can be combined as needed. The system can evolve as medical technology and clinical practice evolve, without disrupting the ICD-10-PCS structure ICD-10-PCS Reference Manual

37 Preliminary 12/10/07 ICD-10-PCS additional characteristics ICD-10-PCS possesses several additional characteristics in response to government and industry recommendations. These characteristics are Standardized terminology within the coding system Standardized level of specificity No diagnostic information No explicit not otherwise specified (NOS) code options Limited use of not elsewhere classified (NEC) code options Standardized terminology Words commonly used in clinical vocabularies may have multiple meanings. This can cause confusion and result in inaccurate data. ICD-10-PCS is standardized and self-contained. Characters and values used in the system are defined in the system. For example, the word excision is used to describe a wide variety of surgical procedures. In ICD-10-PCS, the word excision describes a single, precise surgical objective, defined as Cutting out or off, without replacement, a portion of a body part. For the complete list of root operations and their definitions, please refer to appendix A. No eponyms or common procedure names The terminology used in ICD-10-PCS is standardized to provide precise and stable definitions of all procedures performed. This standardized terminology is used in all ICD-10-PCS code descriptions. As a result, ICD-10-PCS code descriptions do not include eponyms or common procedure names. Two examples from ICD-9-CM are 22.61, Excision of lesion of maxillary sinus with Caldwell-Luc approach, and 51.10, Endoscopic retrograde cholangiopancreatography [ERCP]. In ICD-10-PCS, physicians names are not included in a code description, nor are procedures identified by common terms or acronyms such as appendectomy or CABG. Instead, such procedures are coded to the root operation that accurately identifies the objective of the procedure. The procedures described in the preceding paragraph by ICD-9-CM codes are coded in ICD-10-PCS according to the root operation that matches the objective of the procedure. Here the ICD-10-PCS equivalents would be EXCISION and INSPECTION respectively. By relying on the universal objectives defined in ICD-10-PCS overview 1.23

38 ICD-10-PCS additional characteristics 12/10/07 Preliminary root operations rather than eponyms or specific procedure titles that change or become obsolete, ICD-10-PCS preserves the capacity to define past, present, and future procedures accurately using stable terminology in the form of characters and values. No combination codes With rare exceptions, ICD-10-PCS does not define multiple procedures with one code. This is to preserve standardized terminology and consistency across the system. Procedures that are typically performed together but are distinct procedures may be defined by a single combination code in ICD-9-CM. An example of a combination code in ICD-9-CM is 28.3, Tonsillectomy with adenoidectomy. A procedure that meets the reporting criteria for a separate procedure is coded separately in ICD-10-PCS. This allows the system to respond to changes in technology and medical practice with the maximum degree of stability and flexibility. Standardized level of specificity In ICD-9-CM, one code with its description and includes notes may encompass a vast number of procedure variations while another code defines a single specific procedure. ICD-10-PCS provides a standardized level of specificity for each code, so that each code represents a single procedure variation. The ICD-9-CM code 39.31, Suture of artery, does not specify the artery, whereas the code range , Resection of artery with replacement, provides a fourth-digit subclassification for specifying the artery by anatomical region (thoracic, abdominal, etc.). In ICD-10-PCS, the codes identifying all artery suture and artery replacement procedures possess the same degree of specificity. The ICD-9-CM examples above coded to their ICD-10-PCS equivalents would use the same artery body part values in all codes identifying the respective procedures. In general, ICD-10-PCS code descriptions are much more specific than their ICD-9-CM counterparts, but sometimes an ICD-10-PCS code description is actually less specific. In most cases this is because the ICD-9-CM code contains diagnosis information. The standardized level of code specificity in ICD-10-PCS cannot always take account of these fluctuations in ICD-9-CM level of specificity. Instead, ICD-10-PCS provides a standardized level of specificity that can be predicted across the system ICD-10-PCS Reference Manual

39 Preliminary 12/10/07 ICD-10-PCS additional characteristics Diagnosis information excluded Another key feature of ICD-10-PCS is that information pertaining to a diagnosis is excluded from the code descriptions. ICD-9-CM often contains information about the diagnosis in its procedure codes. Adding diagnosis information limits the flexibility and functionality of a procedure coding system. It has the effect of placing a code off limits because the diagnosis in the medical record does not match the diagnosis in the procedure code description. The code cannot be used even though the procedural part of the code description precisely matches the procedure performed. Diagnosis information is not contained in any ICD-10-PCS code. The diagnosis codes, not the procedure codes, will specify the reason the procedure is performed. NOS code options restricted ICD-9-CM often designates codes as unspecified or not otherwise specified codes. By contrast, the standardized level of specificity designed into ICD-10-PCS restricts the use of broadly applicable NOS or unspecified code options in the system. A minimal level of specificity is required to construct a valid code. In ICD-10-PCS, each character defines information about the procedure and all seven characters must contain a specific value obtained from a single row of a table to build a valid code. Even values such as the sixth-character value Z, NO DEVICE and the seventh-character value Z, NO QUALIFIER, provide important information about the procedure performed. Limited NEC code options ICD-9-CM often designates codes as not elsewhere classified or other specified versions of a procedure throughout the code set. NEC options are also provided in ICD-10-PCS, but only for specific, limited use. In the MEDICAL AND SURGICAL section, two significant not elsewhere classified options are the root operation value Q, REPAIR and the device value Y, OTHER DEVICE. The root operation REPAIR is a true NEC value. It is used only when the procedure performed is not one of the other root operations in the MEDICAL AND SURGICAL section. OTHER DEVICE, on the other hand, is intended to be used to temporarily define new devices that do not have a specific value assigned, until one can be added to the system. No categories of medical or surgical devices are permanently classified to OTHER DEVICE. ICD-10-PCS overview 1.25

40 12/10/07 Preliminary ICD-10-PCS applications ICD-10-PCS code structure results in qualities that optimize the performance of the system in electronic applications, and maximize the usefulness of the coded healthcare data. These qualities include Optimal search capability Consistent character definitions Consistent values wherever possible Code readability Some have argued that, in the world of the electronic health record, the classification system as we know it is outmoded, that classification doesn t matter because a computer is able to find a code with equal ease whether the code has been generated at random or is part of a classification scheme. While this may be true from an IT perspective, assignment of randomly generated code numbers makes it impossible to aggregate data according to related ranges of codes. This is a critical capability for providers, payers, and researchers to make meaningful use of the data. Optimal search capability ICD-10-PCS is designed for maximum versatility in the ability to aggregate coded data. Values belonging to the same character as defined in a section or sections can be easily compared, since they occupy the same position in a code. This provides a high degree of flexibility and functionality for data mining. For example, the body part value 6, STOMACH, retains its meaning for all codes in the MEDICAL AND SURGICAL section that define procedures performed on the stomach. Because the body part value is dependent for its meaning on the body system in which it is found, the body system value D, GASTROINTESTINAL, must also be included in the search. A person wishing to examine data regarding all medical and surgical procedures performed on the stomach could do so simply by searching the code range below. 0D*6*** 1.26 ICD-10-PCS Reference Manual

41 Preliminary 12/10/07 ICD-10-PCS applications Consistent characters and values In the previous example, the value 6 means STOMACH only when the body system value is D, GASTROINTESTINAL. In many other cases, values retain their meaning across a much broader range of codes. This provides consistency and readability. For example, the value 0 in the fifth character defines the approach OPEN and the value 3 in the fifth character defines the approach PERCUTANEOUS across sections 0 4 and 7 9, where applicable. As a result, all open and percutaneous procedures represented by codes in sections 0-4 and 7-9 can be compared based on a single character approach by conducting a query on the code ranges below. [0 4,7-9]***0** vs. [0 4,7-9]***3** Searches can be progressively refined by adding specific values. For example, one could search on a body system value or range of body system values, plus a body part value or range of body part values, plus a root operation value or range of root operation values. To refine the search above, one could add the body system value for GASTROINTESTINAL and the body part value for STOM- ACH to limit the search to open vs. percutaneous procedures performed on the stomach: 0D*60** vs. 0D*63** To refine the search even further and limit the comparison to open and percutaneous biopsies of the stomach, one could add the third-character value for the root operation EXCISION and the seventh-character qualifier DIAGNOSTIC, as below. 0DB60*X vs. 0DB63*X Stability of characters and values across vast ranges of codes provides the maximum degree of functionality and flexibility for the collection and analysis of data. The search capabilities demonstrated above function equally well for all uses of healthcare data: investigating quality of care, resource utilization, risk management, conducting research, determining reimbursement, and many others. Because the character definition is consistent, and only the individual values assigned to that character differ as needed, meaningful comparisons of data over time can be conducted across a virtually infinite range of procedures. ICD-10-PCS overview 1.27

42 ICD-10-PCS applications 12/10/07 Preliminary Code readability ICD-10-PCS resembles a language in the sense that it is made up of semi-independent values combined by following the rules of the system, much the way a sentence is formed by combining words and following the rules of grammar and syntax. As with words in their context, the meaning of any single value is a combination of its position in the code and any preceding values on which it may be dependent. For example, in the MEDICAL AND SURGICAL section, a body part value is always dependent for its meaning on the body system in which it is found. It cannot stand alone as a letter or a number and be meaningful. A fourth-character value of 6 by itself can mean 31 different things, but a fourth-character value of 6 in the context of a second-character value of D means one thing only STOMACH. On the other hand, a root operation value is not dependent on any character but the section for its meaning, and identifies a single consistent objective wherever the third character is defined as root operation. For example, the third-character value T identifies the root operation RESECTION in both the MED- ICAL AND SURGICAL and OBSTETRICS sections. The approach value also identifies a single consistent approach wherever the fifth character is defined as approach. The fifth-character value 3 identifies the approach PERCUTANEOUS in the MEDICAL AND SURGICAL section, the OBSTETRICS section, the ADMINISTRATION section, and others. The sixth-character device value or seventh-character qualifier value identifies the same device or qualifier in the context of the body system where it is found. Although there may be consistencies across body systems or within whole sections, this is not true in all cases. Values in their designated context have a precise meaning, like words in a language. As seen in the code example which began this chapter, 0LB50ZZ represents the text description of the specific procedure Excision of right lower arm and wrist tendon, open approach. Since ICD-10-PCS values in context have a single, precise meaning, a complete, valid code can be read and understood without its accompanying text description, much like one would read a sentence ICD-10-PCS Reference Manual

43 Preliminary 12/10/07 Chapter 2 2Procedures in the Medical and Surgical section

44 12/10/07 Preliminary Contents Procedures in the Medical and Surgical section 2.5 Root operation groups 2.6 Root operations that take out some or all of a body part 2.8 Excision Root operation B 2.9 Resection Root operation T 2.11 Detachment Root operation Destruction Root operation Extraction Root operation D 2.18 Root operations that take out solids/fluids/gases from a body part 2.20 Drainage Root operation Extirpation Root operation C 2.23 Fragmentation Root operation F 2.25 Root operations involving cutting or separation only 2.27 Division Root operation Release Root operation N 2.29 Root operations that put in/put back or move some/all of a body part 2.31 Transplantation Root operation Y 2.32 Reattachment Root operation M 2.34 Transfer Root operation X 2.36 Reposition Root operation S 2.38 Root operations that alter the diameter/route of a tubular body part 2.40 Restriction Root operation V 2.41 Occlusion Root operation L 2.43 Dilation Root operation Bypass Root operation Root operations that always involve a device 2.49 Insertion Root operation H 2.50 Replacement Root operation R 2.52 Change Root operation Removal Root operation P 2.55 Revision Root operation W ICD-10-PCS Reference Manual

45 Preliminary 12/10/07 Root operations involving examination only 2.58 Inspection Root operation J 2.59 Map Root operation K 2.60 Root operations that define other repairs 2.61 Control Root operation Repair Root operation Q 2.63 Root operations that define other objectives 2.65 Fusion Root operation G 2.66 Alteration Root operation Creation Root operation Procedures in the Medical and Surgical section 2.3

46 Preliminary 12/10/07

47 Preliminary 12/10/07 Chapter 2 Procedures in the Medical and Surgical section THIS CHAPTER PROVIDES reference material for the root operations in the MEDICAL AND SURGICAL section of ICD-10-PCS. The vast majority of codes reported in an inpatient setting are found in this section. First, a table presents all root operations in the MEDICAL AND SURGICAL section, organized into logical groups. Following the table are definitions of each root operation, presented in the order shown in the table. Material on each root operation includes Definition, explanation, and examples of the root operation Coding notes as needed A representative procedure excerpt for each root operation, followed by the correct code for the procedure. The code is provided in table excerpt format, along with explanatory notes as needed. Coding exercises that provide example procedures and their corresponding ICD-10-PCS codes, with explanatory notes as needed Procedures in the Medical and Surgical section 2.5

48 12/10/07 Preliminary Root operation groups The MEDICAL AND SURGICAL root operations are divided into groups that share similar attributes. These groups, and the root operations in each, are listed in the table below. Subsequent pages of this chapter provide a definition of each root operation in a group. Root operation Objective of procedure Site of procedure Example Root operations that take out some/all of a body part Excision Cutting out/off without replacement Some of a body part Breast lumpectomy Resection Cutting out/off without replacement All of a body part Total mastectomy Detachment Cutting out/off without replacement Extremity only, any level Amputation above elbow Destruction Eradicating without replacement Some/all of a body part Fulguration of endometrium Extraction Pulling out or off without replacement Some/all of a body part Suction D&C Root operations that take out solids/fluids/gases from a body part Drainage Taking/letting out fluids/gases Within a body part Incision and drainage Extirpation Taking/cutting out solid matter Within a body part Thrombectomy Fragmentation Breaking solid matter into pieces Within a body part Lithotripsy Root operations involving cutting or separation only Division Cutting into/separating a body part Within a body part Neurotomy Release Freeing a body part from constraint Around a body part Adhesiolysis Root operations that put in/put back or move some/all of a body part Transplantation Putting in a living body part from a Some/all of a body part Kidney transplant person/animal Reattachment Putting back a detached body part Some/all of a body part Reattach severed finger Transfer Moving, to function for a similar body part Some/all of a body part Skin transfer flap Reposition Moving, to normal or other suitable location Some/all of a body part Move undescended testicle 2.6 ICD-10-PCS Reference Manual

49 Preliminary 12/10/07 Root operation groups Root Objective of procedure Site of procedure Example operation Root operations that alter the diameter/route of a tubular body part Restriction Partially closing orifice/lumen Tubular body part Gastroesophageal fundoplication Occlusion Completely closing orifice/lumen Tubular body part Fallopian tube ligation Dilation Expanding orifice/lumen Tubular body part Percutaneous transluminal coronary angioplasty (PTCA) Bypass Altering route of passage Tubular body part Coronary artery bypass graft (CABG) Root operations that always involve a device Insertion Putting in non-biological device In/on a body part Central line insertion Replacement Putting in device that replaces a body Some/all of a body part Total hip replacement part Change Exchanging device w/out cutting/ In/on a body part Drainage tube change puncturing Removal Taking out device In/on a body part Central line removal Revision Correcting a malfunctioning/displaced device In/on a body part Revision of pacemaker insertion Root operations involving examination only Inspection Visual/manual exploration Some/all of a body part Diagnostic cystoscopy Map Locating electrical impulses/functional areas Root operations that include other repairs Repair Restoring body part to its normal structure Control Stopping/attempting to stop postprocedural bleed Brain/cardiac conduction mechanism Some/all of a body part Anatomical region Cardiac electrophysiological study Suture laceration Post-prostatectomy bleeding Root operations that include other objectives Fusion Rendering joint immobile Joint Spinal fusion Alteration Modifying body part for cosmetic Some/all of a body part Face lift purposes without affecting function Creation Making new structure for sex change operation Perineum Artificial vagina/penis Procedures in the Medical and Surgical section 2.7

50 12/10/07 Preliminary Root operations that take out some or all of a body part Five root operations represent procedures for taking out or otherwise eradicating some or all of a body part. These root operations are listed in the table below and described in detail in the pages that follow. Root operation Objective of procedure Site of procedure Example Excision Cutting out/off without Some of a body part Breast lumpectomy replacement Resection Cutting out/off without All of a body part Total mastectomy replacement Detachment Cutting out/off without Extremity only, any level Amputation above elbow replacement Destruction Eradicating without replacement Some/all of a body part Fulguration of endometrium Extraction Pulling out or off without replacement Some/all of a body part Suction D&C 2.8 ICD-10-PCS Reference Manual

51 Preliminary 12/10/07 Root operations that take out some or all of a body part Excision Root operation B Excision Definition Cutting out or off, without replacement, a portion of a body part B Explanation The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies. Examples Partial nephrectomy, liver biopsy EXCISION is coded when a portion of a body part is cut out or off using a sharp instrument. All root operations that employ cutting to accomplish the objective allow the use of any sharp instrument, including but not limited to Scalpel Wire Scissors Bone saw Electrocautery tip Coding note: Bone marrow and endometrial biopsies Bone marrow and endometrial biopsies are not coded to the root operation EXCISION. They are coded to EXTRACTION, with the qualifier DIAGNOSTIC (see page 2.18). Example: Excision of sebaceous cyst (right buttock)...the patient was brought in the room and placed on the table in jack knife, prone position and a spinal block was used for anesthesia. She was prepped and draped in the usual sterile manner. A digital rectal examination was performed and we did not notice any communication between mass and rectum. The mass was palpated and a radial transcerse incision was made over the mass. Using blunt and sharp dissection the top of the mass was identified and shown to be a sebaceous cyst. The sebaceous cyst was freed from the surrounding tissue using blunt dissection. The entire cyst was removed. Hemostasis was obtained and the skin was closed using 5-0 Dexon interrupted sutures... Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND SKIN EXCISION BUTTOCK EXTERNAL NO DEVICE NO QUALIFIER SURGICAL 0 H B 8 X Z Z Procedures in the Medical and Surgical section 2.9

52 Root operations that take out some or all of a body part 12/10/07 Preliminary Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Excision of malignant melanoma from skin of right ear Laparoscopy with excision of endometrial implant from left ovary Percutaneous needle core biopsy of right kidney EGD with gastric biopsy Open endarterectomy of left common carotid artery Excision of basal cell carcinoma of lower lip Open excision of tail of pancreas Percutaneous biopsy of right gastrocnemius muscle Sigmoidoscopy with sigmoid polypectomy Open excision of lesion from right Achilles tendon Code 0HB2XZZ 0UB14ZZ 0TB03ZX 0DB68ZX 03BJ0ZZ 0CB1XZZ 0FBG0ZZ 0KBS3ZX 0DBN8ZZ 0LBN0ZZ 2.10 ICD-10-PCS Reference Manual

53 Preliminary 12/10/07 Root operations that take out some or all of a body part Resection Root operation T Resection Definition Cutting out or off, without replacement, all of a body part T Explanation None Examples Total nephrectomy, total lobectomy of lung RESECTION is similar to EXCISION (see page 2.9), except RESECTION includes all of a body part, or any subdivision of a body part that has its own body part value in ICD-10-PCS, while EXCISION includes only a portion of a body part. Coding note: Lymph nodes When an entire lymph node chain is cut out, the appropriate root operation is RESECTION. When a lymph node(s) is cut out, the root operation is EXCISION. Example: Right hemicolectomy...a vertical midline incision was used to enter the abdominal cavity. There was noted to be a mass in the region of the cecum. The mass was easily mobilized and it was felt that a right hemicolectomy was indicated. The right colon was mobilized by incising the white line of Toldt and reflecting colon medially. The loose tissue was taken down bluntly with a hand and adhesions were taken down sharply. The colon was mobilized to the left end up to the level of the hepatic flexure. The mesentery was incised sharply with a knife and down to the level of the root of the mesentery. The mesentery of the right colon and the distal ileum was then taken down between Kellys and tied with #2-0 silk, down to the level of the takeoff vessels. After removing the right colon specimen off the field, a primary anastomosis was planned... Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND SURGICAL GASTROINTEST SYSTEM RESECTION LARGE INTESTINE, RT OPEN NO DEVICE NO QUALIFIER 0 D T F 0 Z Z Procedures in the Medical and Surgical section 2.11

54 Root operations that take out some or all of a body part 12/10/07 Preliminary Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Open resection of cecum Total excision of pituitary gland, open Explantation of left failed kidney, open Open left axillary total lymphadenectomy Laparoscopic-assisted total vaginal hysterectomy Right total mastectomy, open Open resection of papillary muscle Radical retropubic prostatectomy, open Laparoscopic cholecystectomy Endoscopic bilateral total maxillary sinusectomy Code 0DTH0ZZ 0GT00ZZ 0TT10ZZ 07T60ZZ RESECTION is coded for cutting out a chain of lymph nodes. 0UT9FZZ 0HTT0ZZ 02TD0ZZ The papillary muscle refers to the heart and is found in the HEART AND GREAT VESSELS body system. 0VT00ZZ 0FT44ZZ 09TQ4ZZ, 09TR4ZZ 2.12 ICD-10-PCS Reference Manual

55 Preliminary 12/10/07 Root operations that take out some or all of a body part Detachment Root operation 6 Detachment Definition Cutting off all or a portion of an extremity 6 Explanation Cutting off all or part of the upper or lower extremities Examples Below knee amputation, disarticulation of shoulder DETACHMENT represents a narrow range of procedures; it is used exclusively for amputation procedures. DETACHMENT procedure codes are found only in body systems X and Y, because amputations are performed on extremities, across overlapping body layers. Detachment qualifiers The specific qualifiers used for DETACHMENT are dependent on the body part value. Body Part Upper arm and upper leg Value Definition 0 High: Amputation at the proximal portion of the shaft of the humerus or femur 1 Mid: Amputation at the middle portion of the shaft of the humerus or femur 2 Low: Amputation at the distal portion of the shaft of the humerus or femur Hand and foot 0 Complete 4 Complete 1st Ray 5 Complete 2nd Ray 6 Complete 3rd Ray 7 Complete 4th Ray 8 Complete 5th Ray 9 Partial 1st Ray B Partial 2nd Ray C Partial 3rd Ray D Partial 4th Ray F Partial 5th Ray Complete: Amputation through the carpometacarpal joint of the hand, or through the tarsal-metatarsal joint of the foot Partial: Amputation anywhere along the shaft or head of the metacarpal bone of the hand, or of the metatarsal bone of the foot Procedures in the Medical and Surgical section 2.13

56 Root operations that take out some or all of a body part 12/10/07 Preliminary Body Part Thumb, finger, or toe Value Definition 0 Complete: Amputation at the metacarpophalangeal/metatarsal-phalangeal joint 1 High: Amputation anywhere along the proximal phalanx 2 Mid: Amputation through the proximal interphalangeal joint or anywhere along the middle phalanx 3 Low: Amputation through the distal interphalangeal joint or anywhere along the distal phalanx Example: Fifth toe ray amputation...a semi-elliptical incision was made around the base of the left toe with a #15 blade without difficulty. Careful sharp dissection was made down to the bone, and care was taken to avoid the fourth toe s neurovascular bundle. There was obvious osteomyelitis of the proximal phalanx of the fifth toe and the toe itself was disarticulated, the proximal head of the fifth lower extremity metatarsal, without difficulty. Specimens were sent to pathology for culture and examination. Next, both sharp and blunt dissection were used to adequately expose the head of the fifth metatarsal, and this was done without difficulty. A small rongeur was then used to remove the head of the fifth metatarsal, and soft spongy bone was felt beneath this area. Examination of the patient s x-rays revealed that there was an area of cortical lucency at the base of the head of the fifth metatarsal, and the decision was made to extend the amputation to the midshaft of the fifth metatarsal, and this was done without difficulty using a rongeur. The wound was then flushed with normal saline, and bleeding viable tissue was observed throughout the wound. There was adequate flap coverage of the remaining fifth metatarsal... Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND LOWER DETACHMENT FOOT, LEFT OPEN NO DEVICE PARTIAL 5TH SURGICAL EXTREMITIES RAY 0 Y 6 N 0 Z F 2.14 ICD-10-PCS Reference Manual

57 Preliminary 12/10/07 Root operations that take out some or all of a body part Coding note: value Coding exercises The surgeon uses the word toe to describe the amputation, but the operative report says he extends the amputation to the midshaft of the fifth metatarsal, which is the foot, so the qualifier is PARTIAL 5TH RAY. Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Amputation at right elbow level Right below-knee amputation, proximal tibia/fibula Fifth ray carpometacarpal joint amputation, left hand Right leg and hip amputation through ischium DIP joint amputation of right thumb Right wrist joint amputation Trans-metatarsal amputation of foot at left big toe Mid-shaft amputation, right humerus Left fourth toe amputation, mid-proximal phalanx Right above-knee amputation, distal femur Code 0X6B0ZZ 0Y6H0Z1 The qualifier HIGH here means the portion of the tib/fib closest to the knee. 0X6K0Z8 A COMPLETE ray amputation is through the carpometacarpal joint. 0Y620ZZ The HINDQUARTER body part includes amputation along any part of the hip bone. 0X6L0Z3 The qualifier LOW here means through the distal interphalangeal joint. 0X6J0Z0 Amputation at the wrist joint is actually complete amputation of the hand. 0Y6N0Z9 A PARTIAL amputation is through the shaft of the metatarsal bone. 0X680Z2 0Y6W0Z1 The qualifier HIGH here means anywhere along the proximal phalanx. 0Y6C0Z3 Procedures in the Medical and Surgical section 2.15

58 Root operations that take out some or all of a body part 12/10/07 Preliminary Destruction Root operation 5 Destruction Definition Eradicating all or a portion of a body part 5 Explanation Used for the actual physical destruction of all or a portion of a body part by the direct use of energy, force or a destructive agent. None of the body part is taken out. Examples Fulguration of rectal polyp, cautery of skin lesion DESTRUCTION takes out a body part in the sense that it obliterates the body part so it is no longer there. This root operation defines a broad range of common procedures, since it can be used anywhere in the body to treat a variety of conditions, including: Skin and genital warts Nasal and colon polyps Esophageal varices Endometrial implants Nerve lesions Example: Radiofrequency coagulation of the trigeminal nerve...the right cheek was infiltrated dermally with Xylocaine, and a small nick in the skin 2.5 cm lateral to the corner of the mouth was performed with an 18 gauge needle. The radiofrequency needle with 2 mm exposed tip was then introduced using the known anatomical landmarks and under lateral fluoroscopy guidance into the foramen ovale. Confirmation of the placement of the needle was done by the patient grimacing to pain and by the lateral x-ray. The first treatment, 90 seconds in length, was administered with the tip of the needle 3 mm below the clival line at a temperature of 75 degrees C. The needle was then advanced further to the mid clival line and another treatment of similar strength and duration was also administered. Finally the third and last treatment was administered with the tip of the needle about 3 cm above the line. The needle was removed. The patient tolerated the procedure well... Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND CENTRAL DESTRUCTION TRIGEMINAL PERCUTANEOUS NO DEVICE NON- SURGICAL NERVOUS NERVE STEREOTACTIC K 3 Z U 2.16 ICD-10-PCS Reference Manual

59 Preliminary 12/10/07 Root operations that take out some or all of a body part Coding note: Approach value Coding exercises The small nick in the skin does not constitute an open approach. It was made to accommodate the radiofrequency needle. The needle was advanced all the way to the operative site, so the correct approach value is PERCUTANEOUS. Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Cryotherapy of wart on left hand Percutaneous radiofrequency ablation of right vocal cord lesion Left heart catheterization with laser destruction of arrhythmogenic focus, A-V node Cautery of nosebleed Transurethral endoscopic laser ablation of prostate Cautery of oozing varicose vein, left calf Laparoscopy with destruction of endometriosis, bilateral ovaries Laser coagulation of right retinal vessel hemorrhage, percutaneous Talc injection pleurodesis, left side Sclerotherapy of brachial plexus lesion, alcohol injection Code 0H5GXZZ 0C5T3ZZ 02583ZZ 095KXZZ 0V508ZZ 065Y3ZZ The approach is coded PERCUTANEOUS because that is the normal route to a vein. No mention is made of approach, because likely the skin has eroded at that spot. 0U524ZZ 085G3ZZ The RETINAL VESSEL body part values are in the EYE body system. 0B5P3ZZ See section 3, ADMINISTRATION, for applicable injection code ZZ See section 3, ADMINISTRATION, for applicable injection code. Procedures in the Medical and Surgical section 2.17

60 Root operations that take out some or all of a body part 12/10/07 Preliminary Extraction Root operation D Extraction Definition Pulling or stripping out or off all or a portion of a body part D Explanation The body part is pulled or stripped from its location by the use of force (e.g., manual, suction). The qualifier DIAGNOSTIC is used to identify extraction procedures that are biopsies. Examples Dilation and curettage, vein stripping Example: Suction dilation & curettage EXTRACTION is coded when the method employed to take out the body part is pulling or stripping. Minor cutting, such as that used in vein stripping procedures, is included in EXTRACTION if the objective of the procedure is nevertheless met by pulling or stripping. As with all applicable ICD-10-PCS codes, cutting used to reach the procedure site is specified in the approach value....after induction of general anesthesia the patient was placed in the dorsal lithotomy position and appropriately prepped and draped. Successive dilators were placed until the cervix was adequate for insertion of the suction cannula. Suction cannula was placed and suction curettage performed with no residual endometrial lining. The tissue was sent to pathology to rule out endometrial cancer... Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND FEMALE EXTRACTION ENDOMETRIUM VIA NAT./ARTIF. NO DEVICE DIAGNOSTIC SURGICAL REPRODUCTIVE OPENING 0 U D B 7 Z X 2.18 ICD-10-PCS Reference Manual

61 Preliminary 12/10/07 Root operations that take out some or all of a body part Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Forceps total mouth extraction, upper and lower teeth Removal of left thumbnail Extraction of right intraocular lens without replacement, open Laparoscopy with needle aspiration of ova for in-vitro fertilization Non-excisional debridement of skin ulcer, right foot Open stripping of abdominal fascia, right side Hysteroscopy with D&C, diagnostic Liposuction for medical purposes, left upper arm Removal of tattered right ear drum fragments with tweezers Microincisional phlebectomy of spider veins, right lower leg Code 0CDWXZ2, 0CDXXZ2 0HDQXZZ No separate body part value is given for thumbnail, so this is coded to FINGERNAIL. 08DJ0ZZ 0UDN4ZZ 0HDMXZZ 0JD80ZZ 0UDB8ZX 0JDF3ZZ The PERCUTANEOUS approach is inherent in the liposuction technique. 09D77ZZ 06DY3ZZ Procedures in the Medical and Surgical section 2.19

62 12/10/07 Preliminary Root operations that take out solids/fluids/gases from a body part The table below lists the root operations that take out solids, fluids, or gases from a body part. Each is described in detail in the pages that follow. Root operation Objective of procedure Site of procedure Example Drainage Taking/letting out fluids/gases Within a body part Incision and drainage Extirpation Taking/cutting out solid matter Within a body part Thrombectomy Fragmentation Breaking solid matter into pieces Within a body part Lithotripsy 2.20 ICD-10-PCS Reference Manual

63 Preliminary 12/10/07 Root operations that take out solids/fluids/gases from a body part Drainage Root operation 9 Drainage Definition Taking or letting out fluids and/or gases from a body part 9 Explanation The qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies. Examples Thoracentesis, incision and drainage Example: Urinary nephrostomy catheter placement The root operation DRAINAGE is coded for both diagnostic and therapeutic drainage procedures. When drainage is accomplished by putting in a catheter, the device value DRAINAGE DEVICE is coded in the sixth character....using fluoroscopy and sterile technique a needle was placed through the skin into a markedly dilated right renal collecting system. Guidewire was inserted and an 8 French locking catheter was positioned with the dilated right renal pelvis. It was attached to a bag and immediate drainage of urine was evident... Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND URINARY DRAINAGE KIDNEY PELVIS, PERCUTANEOUS DRAINAGE NO QUALIFIER SURGICAL RIGHT DEVICE 0 T Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Routine Foley catheter placement Incision and drainage of external perianal abscess Percutaneous drainage of ascites Laparoscopy with left ovarian cystotomy and drainage Laparotomy with hepatotomy and drain placement for liver abscess, caudate lobe Right knee arthrotomy with drain placement Code 0T9B70Z 0D9QXZZ 0W9G3ZZ This is drainage of the cavity and not the peritoneal membrane itself. 0U914ZZ 0F9300Z 0S9C00Z Procedures in the Medical and Surgical section 2.21

64 Root operations that take out solids/fluids/gases from a body part 12/10/07 Preliminary Procedure Thoracentesis of left pleural effusion Phlebotomy of left median cubital vein for polycythemia vera Percutaneous chest tube placement for right pneumothorax Endoscopic drainage of left ethmoid sinus Code 0W9B3ZZ This is drainage of the pleural cavity. 059F3ZZ The median cubital vein is a branch of the cephalic vein. 0W9930Z 099V4ZZ 2.22 ICD-10-PCS Reference Manual

65 Preliminary 12/10/07 Root operations that take out solids/fluids/gases from a body part Extirpation Root operation C Extirpation Definition Taking or cutting out solid matter from a body part C Explanation The solid matter may be an abnormal byproduct of a biological function or a foreign body. The solid matter is imbedded in a body part, or is in the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces. No appreciable amount of the body part is taken out. Examples Thrombectomy, choledocholithotomy Example: De-clotting of AV dialysis graft EXTIRPATION represents a range of procedures where the body part itself is not the focus of the procedure. Instead, the objective is to remove solid material such as a foreign body, thrombus, or calculus from the body part....the right upper extremity was properly prepped and draped. Local anesthesia was used to explore the graft. A transverse incision in the previous site of the incision, 1 cm below the elbow crease, was performed. The venous limb of the graft was dissected free up to the venous anastomosis. A small incision on the graft was performed. Then a #3 Fogarty catheter was passed on the venous side. The cephalic vein was found obstructed, not on the anastomotic site, but about 4 cm proximal to the anastomosis. A large number of clots were extracted. After the embolectomy a good back flow from the venous side was obtained. Then the embolectomy was performed throughout the limb on the arterial side. More clots were extracted and a good arterial flow was obtained. The procedure was concluded, closing the incision on the graft with 6-0 prolene... Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND UPPER VEINS EXTIRPATION CEPHALIC VEIN, OPEN NO DEVICE NO QUALIFIER SURGICAL RIGHT 0 5 C D 0 Z Z Coding note: body part value Do not code separate body parts based on the words venous side and arterial side in the procedure report. They refer to the two ends of the cephalic vein used to create the fistula. Procedures in the Medical and Surgical section 2.23

66 Root operations that take out solids/fluids/gases from a body part 12/10/07 Preliminary Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Removal of foreign body, right cornea Percutaneous mechanical thrombectomy, left brachial artery Esophagogastroscopy with removal of bezoar from stomach Foreign body removal, skin of left thumb Transurethral cystoscopy with removal of bladder stone Forceps removal of foreign body in right nostril Laparoscopy with excision of old suture from mesentery Incision and removal of right lacrimal duct stone Non-incisional removal of intraluminal foreign body from vagina Open excision of retained sliver, subcutaneous tissue of left foot Code 08C8XZZ 03C83ZZ 0DC68ZZ 0HCGXZZ There is no specific value for thumb skin, so the procedure is coded to the hand. 0TCB8ZZ 09CKXZZ Nostril is coded to the NOSE body part value. 0DCV4ZZ 08CX0ZZ 0UCG7ZZ The approach EXTERNAL is also a possibility. It is assumed here that since the patient went to the doctor to have the object removed, that it was not in the vaginal orifice. 0JCR0ZZ 2.24 ICD-10-PCS Reference Manual

67 Preliminary 12/10/07 Root operations that take out solids/fluids/gases from a body part Fragmentation Root operation F Fragmentation Definition Breaking solid matter in a body part into pieces F Explanation The solid matter may be an abnormal byproduct of a biological function or a foreign body. Physical force (e.g., manual, ultrasonic) applied directly or indirectly through intervening body parts is used to break the solid matter into pieces. The pieces of solid matter are not taken out, but are eliminated or absorbed through normal biological functions. Examples Extracorporeal shockwave lithotripsy, transurethral lithotripsy Example: ESWL of left kidney FRAGMENTATION is coded for procedures to break up, but not remove, solid material such as a calculus or foreign body. This root operation includes both direct and extracorporeal FRAGMEN- TATION procedures. With the patient having been identified, under satisfactory IV sedation and using the MFL 1000 for extracorporeal shock wave lithotripsy, 1000 shocks were delivered to the stone in the lower pole of the left kidney, and 800 shocks were delivered to the stone in the upper pole of the same, with change in shape and density of the stone indicating fragmentation. The patient tolerated the procedure well... Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND URINARY FRAGMENT. KIDNEY PELVIS, EXTERNAL NO DEVICE NO QUALIFIER SURGICAL LEFT 0 T F 4 X Z Z Procedures in the Medical and Surgical section 2.25

68 Root operations that take out solids/fluids/gases from a body part 12/10/07 Preliminary Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Extracorporeal shock-wave lithotripsy (ESWL), bilateral ureters Endoscopic Retrograde Cholangiopancreatography (ERCP) with lithotripsy of common bile duct stone Thoracotomy with crushing of pericardial calcifications Transurethral cystoscopy with fragmentation of bladder calculus Hysteroscopy with intraluminal lithotripsy of left fallopian tube calcification Code 0TF6XZZ, 0TF7XZZ The bilateral ureter body part value is not available for the root operation FRAGMENTATION, so the procedures are coded separately. 0FF98ZZ ERCP is performed through the mouth to the biliary system via the duodenum, so the approach value is VIA NATURAL OR ARTIFICIAL OPENING ENDOSCOPIC. 02FN0ZZ 0TFB8ZZ 0UF68ZZ 2.26 ICD-10-PCS Reference Manual

69 Preliminary 12/10/07 Root operations involving cutting or separation only The table below lists the root operations that cut or separate a body part. Each is described in detail in the pages that follow. Root operation Objective of procedure Site of procedure Example Division Cutting into/separating a body Within a body part Neurotomy part Release Freeing a body part from constraint Around a body part Adhesiolysis Procedures in the Medical and Surgical section 2.27

70 Root operations involving cutting or separation only 12/10/07 Preliminary Division Root operation 8 Division Definition Separating, without taking out, a body part 8 Explanation All or a portion of the body part is separated into two or more portions. Examples Spinal cordotomy, osteotomy The root operation DIVISION is coded when the objective of the procedure is to cut into, transect, or otherwise separate all or a portion of a body part. When the objective is to cut or separate the area around a body part, the attachments to a body part, or between subdivisions of a body part that are causing abnormal constraint, then the root operation RELEASE is coded instead. Example: Anal sphincterotomy Manual examination of the rectum and anus was done, and examination showed that the patient has an anterior anal fissure. For that reason, lateral sphincterotomy was done at the 3 o clock position using the closed approach, dividing only the internal sphincter using the #11 blade... Character 1 Section Character 2 GASTROINTEST. SYSTEM Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND DIVISION ANAL PERCUTANEOUS NO DEVICE NO QUALIFIER SURGICAL SPHINCTER 0 D 8 R 3 Z Z Coding note: Approach value Coding exercises This is coded to the PERCUTANEOUS approach, because the procedure report says that the sphincterotomy was done using the closed approach, dividing only the internal sphincter. Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Division of right foot tendon, percutaneous Left heart catheterization with division of bundle of HIS Open osteotomy of capitate, left hand EGD with sphincterotomy of pylorus Sacral rhizotomy for pain control, percutaneous Code 0L8V3ZZ 02883ZZ 0P8N0ZZ The capitate is one of the carpal bones of the hand. 0D878ZZ 018R3ZZ 2.28 ICD-10-PCS Reference Manual

71 Preliminary 12/10/07 Root operations involving cutting or separation only Release Root operation N Release Definition Freeing a body part N Explanation Eliminating an abnormal constraint of a body part by cutting or by use of force. Some of the restraining tissue may be taken out but none of the body part is taken out. Examples Adhesiolysis, carpal tunnel release Example: Release of median nerve The objective of procedures represented in the root operation RELEASE is to free a body part from abnormal constraint. RELEASE procedures are coded to the body part being freed. The procedure can be performed on the area around a body part, on the attachments to a body part, or between subdivisions of a body part that are causing the abnormal constraint....the right arm was scrubbed with Betadine and prepped and draped in the usual sterile fashion. A well-padded tourniquet was fixed to the right proximal arm but not inflated until after draping. After draping, the right arm was exsanguinated with a combination of elevation and an Esmarch bandage, placing a sponge in the palm. The tourniquet was inflated to 250. A transverse incision was made at the level of the proximal wrist crease between the palmaris longus and the flexor carpi ulnaris sharply through the skin with a knife, and subcutaneous tissue was dissected by blunt spreading. The volar fascia was identified and a transverse incision was made sharply with a knife. The flat synovial retractor was pushed through the underneath of the transverse carpal ligament, removing synovium from beneath the ligament. The entire carpal tunnel and the fat pad distally was visualized. The blade was inserted into the carpal tunnel, was elevated at the distal edge of the transverse carpal ligament, and was pulled proximally, spreading and cutting through the transverse carpal ligament. It was visualized that the entire median nerve had been released, and that configuration of the end of the transverse carpal ligament was a rectangle, denoting that both the deep and the superficial fibers had been cut. The wound was then copiously irrigated with saline... Procedures in the Medical and Surgical section 2.29

72 Root operations involving cutting or separation only 12/10/07 Preliminary Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND PERIPHERAL RELEASE MEDIAN NERVE OPEN NO DEVICE NO QUALIFIER SURGICAL NERVOUS 0 1 N 5 0 Z Z Coding note: body part value Coding exercises The body part value assigned is the structure released and not the structure cut to obtain the release, where the two differ. The transverse carpal ligament was cut to release the median nerve and not for its own sake. Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Laparotomy with exploration and adhesiolysis of right ureter Incision of scar contracture, right elbow Frenulotomy for treatment of tongue-tie syndrome Right shoulder arthroscopy with coracoacromial ligament release Mitral valvulotomy for release of fused leaflets, open approach Percutaneous left Achilles tendon release Laparoscopy with lysis of peritoneal adhesions Manual rupture of right shoulder joint adhesions under general anesthesia Open posterior tarsal tunnel release Laparoscopy with freeing of left ovary and fallopian tube Code 0TN60ZZ 0HNDXZZ The skin of the elbow region is coded to the lower arm. 0CN7XZZ The frenulum is coded to the body part value TONGUE. 0MN14ZZ 02NG0ZZ 0LNP3ZZ 0DNW4ZZ 0RNJXZZ 01NG0ZZ The nerve released in the posterior tarsal tunnel is the tibial nerve. 0UN14ZZ, 0UN64ZZ 2.30 ICD-10-PCS Reference Manual

73 Preliminary 12/10/07 Root operations that put in/put back or move some/all of a body part The table below lists the root operations that put in, put back, or move some or all of a body part. Each is described in detail in the pages that follow. Root operation Objective of procedure Site of procedure Example Transplantation Putting in a living body part from Some/all of a body part Kidney transplant a person/animal Reattachment Putting back a detached body Some/all of a body part Reattach finger part Transfer Moving a body part to function Some/all of a body part Skin transfer flap for a similar body part Reposition Moving a body part to normal or other suitable location Some/all of a body part Move undescended testicle Procedures in the Medical and Surgical section 2.31

74 Root operations that put in/put back or move some/all of a body part 12/10/07 Preliminary Transplantation Root operation Y Transplantation Y Definition Explanation Examples Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part The native body part may or may not be taken out, and the transplanted body part may take over all or a portion of its function. Kidney transplant, heart transplant A small number of procedures is represented in the root operation TRANSPLANTATION and includes only the body parts currently being transplanted. values specify the genetic compatibility of the body part transplanted. Example: Right kidney transplant (syngeneic)...the abdomen was sterilely prepped and draped in the usual fashion and incision in the right flank, the Gibson technique, performed. In doing so the right pelvis was entered and Bookwalter retractor appropriately positioned to provide exposure of the external iliac artery and vein. The artery was placed on vessel loop retraction. We then proceeded with the kidney transplant, and the kidney which was trimmed on the back table was brought into the field. The right renal vein was cut short without reconstruction of the inferior vena cava, and single ureter was identified. Kidney was brought up in an ice blanket and an end-to-end anastomosis was performed in the usual fashion with 5-0 Prolene between donor renal vein and external iliac vein on the right. The long renal artery was brought into view, and end-to-side anastomosis performed in the usual fashion with 5-0 Prolene. We then turned our attention to performing the neoureterocystostomy after appropriate positioning of the graft and evaluation of the vessels. After the anastomosis was completed there was no evidence of leak. A Blake drain was brought out through a stab incision and the tip of the drain placed near the neoureterocystostomy and both wounds were closed. The infrainguinal wound was closed with running 3-0 Vicryl and the kidney transplant wound was closed with #1 PDS ICD-10-PCS Reference Manual

75 Preliminary 12/10/07 Root operations that put in/put back or move some/all of a body part Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND URINARY TRANSPLANT. KIDNEY, RIGHT OPEN NO DEVICE SYNGENEIC SURGICAL 0 T Y 0 0 Z 1 Coding note: bone marrow transplant Coding exercises Bone marrow transplant procedures are coded in section 3 ADMINISTRATION to the root operation 2 TRANSFUSION. Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Left cornea transplant using organ donor matched cornea Orthotopic heart transplant using porcine heart Right lung transplant, open, using organ donor match Transplant of large intestine, organ donor match Left kidney/pancreas organ bank transplant Code 08Y9XZ0 02YA0Z2 The donor heart comes from an animal (pig), so the qualifier value is ZOOPLASTIC. 0BYK0Z0 0DYE0Z0 0FYG0Z0, 0TY10Z0 Procedures in the Medical and Surgical section 2.33

76 Root operations that put in/put back or move some/all of a body part 12/10/07 Preliminary Reattachment Root operation M Reattachment M Definition Explanation Examples Putting back in or on all or a portion of a separated body part to its normal location or other suitable location Vascular circulation and nervous pathways may or may not be reestablished. Reattachment of hand, reattachment of avulsed kidney Procedures coded to REATTACHMENT include putting back a body part that has been cut off or avulsed. Nerves and blood vessels may or may not be reconnected in a REATTACHMENT procedure. Example: Complex reattachment, left index finger A sharp debridement of grossly contaminated tissue was carried out. It was noted that the extensor mechanism distal to the PIP joint had been lost. There were circumferential lacerations about the finger, save for a cutaneous bridge and ulnar vascular pedicle present at the PIP level. Nonviable bony fragments were removed and then the distal portion of the PIP joint was reshaped with removal of cartilage using double- rongeurs. It was noted that the fractures through the proximal phalanx extended longintudinally. Stabilization was then carried out, with K-wire brought down through the distal finger, out through the fingertip, and then back into the proximal phalanx centrally. The A2 pulley was restored, using figure of eight interrupted sutures of 4 and 5-0 Vicryl, reapproximating the flexor tendons. The extensor mechanisms and tendons were repaired using 4 and 5-0 Vicryl, and anchored to the periosteum on the middle phalanx. A digital nerve was then carried out on the radial aspect of the digit at the PIP joint level using interrupted sutures of 9-0 Ethilon beneath the microscope. At this point, the skin was trimmed, removing skin margins, and then multiple lacerations were closed with 5-0 Prolene... Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part INDEX FINGER, LEFT Character 5 Approach Character 6 Device Character 7 MEDICAL AND UPPER REATTACHMENT OPEN NO DEVICE NO QUALIFIER SURGICAL EXTREMITIES 0 X M P 0 Z Z 2.34 ICD-10-PCS Reference Manual

77 Preliminary 12/10/07 Root operations that put in/put back or move some/all of a body part Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Replantation of avulsed scalp Reattachment of severed right ear Reattachment of traumatic left gastrocnemius avulsion, open Closed replantation of three avulsed teeth, lower jaw Reattachment of severed left hand Code 0HM0XZZ 09M0XZZ 0KMT0ZZ 0CMXXZ1 0XMK0ZZ Procedures in the Medical and Surgical section 2.35

78 Root operations that put in/put back or move some/all of a body part 12/10/07 Preliminary Transfer Root operation X Transfer X Definition Explanation Examples Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part The body part transferred remains connected to its vascular and nervous supply. Tendon transfer, skin pedicle flap transfer The root operation TRANSFER is used to represent procedures where a body part is moved to another location without disrupting its vascular and nervous supply. In select musculoskeletal body systems, a qualifier is used to specify procedures involving composite tissue transfers, such as musculocutaneous flap transfer. Example: Fasciocutaneous flap from scalp to cheek...development of the plane of dissection was completed into the superficial temporal fascia. Development of subgaleal dissection posteriorly was then completed, a distance of 7-8 cm, with hemostasis by electrocautery. The flaps were advanced to the cheek defect and secured with 2-0 inverted PDS sutures and 3-0 inverted Monocryl... Character 1 Section Character 2 SUBCU. TISSUE AND FASCIA Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND TRANSFER SCALP OPEN NO DEVICE SKIN, SUBCU. SURGICAL AND FASCIA 0 J X 0 0 Z C Coding note: body system value The body system value describes the deepest tissue layer in the flap. The qualifier can be used to describe the other tissue layers, if any, being transferred ICD-10-PCS Reference Manual

79 Preliminary 12/10/07 Root operations that put in/put back or move some/all of a body part Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Right hand open palmaris longus tendon transfer Endoscopic radial to median nerve transfer Fasciocutaneous flap closure of left thigh, open Transfer left index finger to left thumb position, open Percutaneous fascia transfer to fill defect, anterior neck Trigeminal to facial nerve transfer, percutaneous endoscopic Endoscopic left leg flexor hallucis longus tendon transfer Right scalp advancement flap to right temple Bilateral TRAM pedicle flap reconstruction status post mastectomy, muscle only, open Skin transfer flap closure of complex open wound, left lower back Code 0LX70ZZ 01X64Z5 0JXM0ZC The qualifier identifies the body layers in addition to fascia included in the procedure. 0XXP0ZM 0JX43ZZ 00XK4ZM 0LXP4ZZ 0HX0XZZ 0KXK0ZZ, 0KXL0ZZ The transverse rectus abdominus muscle (TRAM) flap is coded for each flap developed. 0HX6XZZ Procedures in the Medical and Surgical section 2.37

80 Root operations that put in/put back or move some/all of a body part 12/10/07 Preliminary Reposition Root operation S Reposition S Definition Explanation Examples Moving to its normal location or other suitable location all or a portion of a body part The body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location. Reposition of undescended testicle, fracture reduction REPOSITION represents procedures for moving a body part to a new location. The range of REPOSITION procedures includes moving a body part to its normal location, or moving a body part to a new location to enhance its ability to function. Example: Reposition of undescended right testicle from pelvic region to scrotum...following satisfactory induction of general anesthesia, an incision was made in the inguinal region and dissection carried down to the pelvic cavity, where the right testis was located and mobilized. The spermatic cord was located and freed from surrounding tissue, and its length judged to be sufficient. A one centimeter incision was made in the scrotum and a pouch created in the usual fashion. The right testicle was mobilized down through the inguinal canal into the scrotum, and stitched in place. Meticulous hemostasis was obtained, and the incisions closed in layers Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND MALE REPOSITION TESTIS, RIGHT OPEN NO DEVICE NO QUALIFIER SURGICAL REPRODUCTIVE 0 V S 9 0 Z Z 2.38 ICD-10-PCS Reference Manual

81 Preliminary 12/10/07 Root operations that put in/put back or move some/all of a body part Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Open fracture reduction, right tibia Laparoscopy with gastropexy for malrotation Left knee arthroscopy with reposition of anterior cruciate ligament Open transposition of ulnar nerve Closed reduction with percutaneous internal fixation of right femoral neck fracture Code 0QSG0ZZ 0DS64ZZ 0MSP4ZZ 01S40ZZ 0QS634Z Procedures in the Medical and Surgical section 2.39

82 12/10/07 Preliminary Root operations that alter the diameter/route of a tubular body part The table below lists the root operations that alter the diameter or route of a tubular body part. Tubular body parts are defined in ICD-10-PCS as those hollow body parts that provide a route of passage for solids, liquids, or gases. They include the cardiovascular system, and body parts such as those contained in the gastrointestinal tract, genitourinary tract, biliary tract, and respiratory tract. Each root operation is described in detail in the pages that follow. Root operation Objective of procedure Site of procedure Example Restriction Partially closing orifice/ Tubular body part Gastroesophageal fundoplication lumen Occlusion Completely closing orifice/ Tubular body part Fallopian tube ligation lumen Dilation Expanding orifice/lumen Tubular body part Percutaneous transluminal coronary angioplasty (PTCA) Bypass Altering route of passage Tubular body part Coronary artery bypass graft (CABG) 2.40 ICD-10-PCS Reference Manual

83 Preliminary 12/10/07 Root operations that alter the diameter/route of a tubular body part Restriction Root operation V Restriction Definition Partially closing an orifice or the lumen of a tubular body part V Explanation The orifice can be a natural orifice or an artificially created orifice. Examples Esophagogastric fundoplication, cervical cerclage The root operation RESTRICTION is coded when the objective of the procedure is to narrow the diameter of a tubular body part or orifice. RESTRICTION includes both intraluminal or extraluminal methods for narrowing the diameter. Example: Laparoscopic gastroesophageal fundoplication Insufflation was accomplished through a 5 infraumbilical incision. Five separate 5 mm ports were placed under direct visualization other than the initial port. Laparoscopy revealed a large hiatal hernia. Electrocautery was used to free up adhesions from the hernia sac to the stomach. Next, the fundus which had been mobilized was brought down into the stomach and it was felt there was enough mobilization to perform a fundoplication. A generous loose fundoplication was then performed by wrapping the fundus around the esophagus. Interrupted 0 Ethibond sutures were used to secure the stomach in this fashion. There was generally good hemostasis throughout the case. All instruments were removed and ports closed Character 1 Section Character 2 GASTROINTEST. SYSTEM Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND RESTRICTION ESOPHAGOGAST PERCUTANEOUS NO DEVICE NO QUALIFIER SURGICAL JUNCTION ENDOSCOPIC 0 D V 4 4 Z Z Procedures in the Medical and Surgical section 2.41

84 Root operations that alter the diameter/route of a tubular body part 12/10/07 Preliminary Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Trans-vaginal intraluminal cervical cerclage Thoracotomy with banding of left pulmonary artery using extraluminal device Restriction of thoracic duct with intraluminal stent, percutaneous Craniotomy with clipping of cerebral aneurysm Non-incisional, trans-nasal placement of restrictive stent in right lacrimal duct Code 0UVC7DZ 02VR0CZ 07VK3DZ 03VG0CZ A clip is placed lengthwise on the outside wall of the widened portion of the vessel. 08VX7DZ 2.42 ICD-10-PCS Reference Manual

85 Preliminary 12/10/07 Root operations that alter the diameter/route of a tubular body part Occlusion Root operation L Occlusion Definition Completely closing an orifice or the lumen of a tubular body part L Explanation The orifice can be a natural orifice or an artificially created orifice. Examples Fallopian tube ligation, ligation of inferior vena cava The root operation OCCLUSION is coded when the objective of the procedure is to close off a tubular body part or orifice. OCCLUSION includes both intraluminal or extraluminal methods of closing off the body part. Division of the tubular body part prior to closing it is an integral part of the OCCLUSION procedure. Example: Uterine artery embolization catheter was advanced over a 0.18 Terumo gold guidewire and advanced several centimeters superselectively into the left uterine artery. Contrast injection was performed here, confirming filling of the uterine artery and subsequent opacification of large vascular structures in the uterus compatible with uterine fibroids. A syringe and a half of micron biospheres was then instilled slowly through the catheter, and at the conclusion of this infusion there was cessation of flow through the uterine artery. The catheter was then removed and hemostasis achieved... Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND LOWER OCCLUSION COMMON ILIAC PERCUTANEOUS INTRALUMINAL NO QUALIFIER SURGICAL ARTERIES ARTERY, LEFT DEVICE 0 4 L D 3 D Z Coding note: body part value Because the uterine artery is not identified as a separate body part value, it is coded to the closest proximal branch identified as a body part value (Guideline B4.12) For the complete list of draft coding guidelines, please refer to appendix B. Procedures in the Medical and Surgical section 2.43

86 Root operations that alter the diameter/route of a tubular body part 12/10/07 Preliminary Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Percutaneous ligation of esophageal vein Percutaneous embolization of left internal carotid-cavernous fistula Laparoscopy with bilateral occlusion of fallopian tubes using Hulka extraluminal clips Open suture ligation of failed AV graft, left brachial artery Percutaneous embolization of vascular supply, intracranial meningioma Code 06L33ZZ 03LL3DZ 0UL74CZ 03L80ZZ 03LG3DZ 2.44 ICD-10-PCS Reference Manual

87 Preliminary 12/10/07 Root operations that alter the diameter/route of a tubular body part Dilation Root operation 7 Dilation Definition Expanding an orifice or the lumen of a tubular body part 7 Explanation The orifice can be a natural orifice or an artificially created orifice. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part. Examples Percutaneous transluminal angioplasty, pyloromyotomy Example: PTCA of left anterior descending The root operation DILATION is coded when the objective of the procedure is to enlarge the diameter of a tubular body part or orifice. DILATION includes both intraluminal or extraluminal methods of enlarging the diameter. A device placed to maintain the new diameter is an integral part of the DILATION procedure, and is coded to a sixth-character device value in the DILATION procedure code. under 1% Lidocaine local anesthesia, the right femoral artery was entered by the Seldinger technique and a #7 French sheath was placed. A Judkins left guiding catheter was advanced to the left coronary ostium and using a.014 Entrée wire and a 2.5 x 30 mm Panther balloon, it was easily placed across the lesion in the left anterior descending. The balloon was inflated times two for five minutes for up to 9 atmospheres. Angiography demonstrated an excellent result Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND HEART AND DILATION CORONARY PERCUTANEOUS NO DEVICE NO QUALIFIER SURGICAL GR.VESSELS ART., ONE SITE Z Z Procedures in the Medical and Surgical section 2.45

88 Root operations that alter the diameter/route of a tubular body part 12/10/07 Preliminary Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure ERCP with balloon dilation of common bile duct PTCA of two coronary arteries, LAD with stent placement, RCA with no stent Cystoscopy with intraluminal dilation of bladder neck stricture Open dilation of old anastomosis, left femoral artery Dilation of upper esophageal stricture, direct visualization, with Bougie sound PTA of right brachial artery stenosis Trans-nasal dilation and stent placement in right lacrimal duct Hysteroscopy with balloon dilation of bilateral fallopian tubes Tracheoscopy with intraluminal dilation of tracheal stenosis Cystoscopy with dilation of left ureteral stricture, with stent placement Code 0F798ZZ 02703DZ, 02703ZZ A separate procedure is coded for each artery dilated, since the device value differs for each artery. 0T7C8ZZ 047L0ZZ 0D717ZZ 03773ZZ 087X7DZ 0U778ZZ 0B718ZZ 0T778DZ 2.46 ICD-10-PCS Reference Manual

89 Preliminary 12/10/07 Root operations that alter the diameter/route of a tubular body part Bypass Root operation 1 Bypass Definition Altering the route of passage of the contents of a tubular body part 1 Explanation Rerouting contents around an area of a body part to another distal (downstream) area in the normal route; rerouting the contents to another different but similar route and body part; or to an abnormal route and another dissimilar body part. It includes one or more concurrent anastomoses with or without the use of a device such as autografts, tissue substitutes and synthetic substitutes. Examples Coronary artery bypass, colostomy formation Example: Aorto-bifemoral bypass graft BYPASS is coded when the objective of the procedure is to reroute the contents of a tubular body part. The range of BYPASS procedures includes normal routes such as those made in coronary artery bypass procedures, and abnormal routes such as those made in colostomy formation procedures. the patient was prepped and draped, and groin incisions were opened. The common femoral vein and its branches were isolated and Teflon tapes were placed around the vessels. The aorta and iliacs were mobilized. Bleeding points were controlled with electrocautery and Liga clips. Tapes were placed around the vessel, the vessel measured, and the aorta was found to be 12 mm. A 12 x 7 bifurcated microvelour graft was then preclotted with the patient s own blood. An end-to-end anastomosis was made on the aorta and the graft using a running suture of 2-0 Prolene. The limbs were taken down through tunnels noting that the ureters were anterior, and at this point an end-to-side anastomosis was made between the graft and the femoral arteries with running suture of 4-0 Prolene. The inguinal incisions were closed Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 BIL. FEMORAL ARTERIES MEDICAL AND LOWER BYPASS ABDOMINAL OPEN SYNTHETIC SURGICAL ARTERIES AORTA SUBSTITUTE J K Procedures in the Medical and Surgical section 2.47

90 Root operations that alter the diameter/route of a tubular body part 12/10/07 Preliminary Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Open gastric bypass with Roux-en-Y limb to jejunum Right temporal artery to intracranial artery bypass using goretex graft, open Tracheostomy formation with tracheostomy tube placement, percutaneous PICVA (Percutaneous in-situ coronary venous arterialization) of single coronary artery Open left femoral-popliteal artery bypass using cadaver vein graft Shunting of intrathecal cerebrospinal fluid to peritoneal cavity using synthetic shunt Colostomy formation, open, transverse colon to abdominal wall Open urinary diversion, left ureter, using ileal conduit to skin CABG of LAD using left internal mammary artery, open off-bypass Open pleuroperitoneal shunt, right pleural cavity, using synthetic device Code 0D160ZA 031S0JG 0B113F D4 041L0KL 00160J6 0D1L0Z4 0T170ZC 02100Z9 0W190JG 2.48 ICD-10-PCS Reference Manual

91 Preliminary 12/10/07 Root operations that always involve a device The table below lists the root operations that always involve a device. Each is described in detail in the pages that follow. Root operation Objective of procedure Site of procedure Example Insertion Putting in non-biological device In/on a body part Central line insertion Replacement Putting in device that replaces a Some/all of a body part Total hip replacement body part Change Exchanging device w/out cutting/ In/on a body part Drainage tube change puncturing Removal Taking out device In/on a body part Central line removal Revision Correcting a malfunctioning/ displaced device In/on a body part Revision of pacemaker insertion Procedures in the Medical and Surgical section 2.49

92 Root operations that always involve a device 12/10/07 Preliminary Insertion Root operation H Insertion H Definition Explanation Examples Putting in a non-biological device that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part None Insertion of radioactive implant, insertion of central venous catheter The root operation INSERTION represents those procedures where the sole objective is to put in a device without doing anything else to a body part. Procedures typical of those coded to INSERTION include putting in a vascular catheter, a pacemaker lead, or a tissue expander. Example: Port-a-cath placement the right chest and neck were prepped and draped in the usual manner and 10 cc s of 1% Lidocaine were injected in the right infraclavicular area. The right subclavian vein was then punctured and a wire was passed through the needle into the superior vena cava. This was documented by fluoroscopy. Introducer kit was introduced into the subclavian vein and the Port-a-cath was placed through the introducer and by fluoroscopy was placed down to the superior vena cava. The pocket was then made over the right pectoralis major muscle, superior to the breast, and the Port-a-cath reservoir was placed into this pocket and tacked down with #0 Prolene sutures. The catheter was then tunneled through a subcutaneous tunnel to this receptacle. Hemostasis was achieved and the subcutaneous tissue closed Character 1 Section Character 2 HEART AND GR. VESSELS Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND INSERTION SUPERIOR PERCUTANEOUS INFUSION NO QUALIFIER SURGICAL VENA CAVA DEVICE 0 2 H V 3 3 Z 2.50 ICD-10-PCS Reference Manual

93 Preliminary 12/10/07 Root operations that always involve a device Character 1 Section Character 2 Body System Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND SUBCU.TISSUE INSERTION CHEST OPEN RESERVOIR NO QUALIFIER SURGICAL AND FASCIA 0 J H 6 0 W Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Percutaneous insertion of spinal neurostimulator lead, lumbar spinal cord Percutaneous placement of pacemaker lead in left atrium Open placement of dual chamber pacemaker generator in chest wall Percutaneous placement of venous central line in right internal jugular Open insertion of multiple channel cochlear implant, left ear Percutaneous placement of Swan-Ganz catheter in superior vena cava Bronchoscopy with insertion of brachytherapy seeds, right main bronchus Placement of intrathecal infusion pump for pain management, percutaneous Open placement of bone growth stimulator, left femoral shaft Cystoscopy with placement of brachytherapy seeds in prostate gland Code 00HY3MZ 02H73MZ 0JH60P2 05HM33Z 09HE0S3 02HV32Z The Swan-Ganz catheter is coded to the device value MONITORING DEVICE because it monitors pulmonary artery output. 0BH381Z 0JH733Z The device resides principally in the subcutaneous tissue of the back, so it is coded to body system J. 0QH90MZ 0VH081Z Procedures in the Medical and Surgical section 2.51

94 Root operations that always involve a device 12/10/07 Preliminary Replacement Root operation R Replacement R Definition Explanation Examples Putting in or on biological or synthetic material that physically takes the place of all or a portion of a body part The biological material is non-living, or the biological material is living and from the same individual. The body part may have been previously taken out, previously replaced, or may be taken out concomitantly with the Replacement procedure. If the body part has been previously replaced, a separate Removal procedure is coded for taking out the device used in the previous replacement. Total hip replacement, free skin graft The objective of procedures coded to the root operation REPLACEMENT is to put in a device that takes the place of some or all of a body part. REPLACEMENT encompasses a wide range of procedures, from joint replacements to grafts of all kinds. Example: Prosthetic lens implantation a superior peritomy was made on the left eye and adequate hemostasis was achieved using eraser cautery. A posterior one-half thickness groove was placed posterior to the blue line. This was beveled forward toward clear cornea. The anterior chamber was entered at the 11:30 position with a blade. The eye was filled with viscoelastic substance. A can-opener type capsulotomy was performed with a cystotome. Hydrodissection was carried out and the lens was rocked gently with a cystotome to loosen it from the cortex. The wound was then opened with corneal scleral scissors. The lens was prolapsed in the anterior chamber and removed. The anterior chamber was then temporarily closed with 8-0 Vicryl sutures and cortical clean-up was performed. One of the sutures was removed and a posterior chamber intraocular lens (Alcon model #MZ50BD) was inspected, rinsed, and placed into a capsular bag. Miochol was then instilled into the anterior chamber. The conjunctiva was pulled over the incision and cauterized into place Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND EYE REPLACEMENT LENS, LEFT OPEN SYNTHETIC NO QUALIFIER SURGICAL SUBSTITUTE 0 8 R K 0 J Z 2.52 ICD-10-PCS Reference Manual

95 Preliminary 12/10/07 Root operations that always involve a device Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Full-thickness skin graft to right lower arm, autograft (do not code graft harvest for this exercise) Excision of necrosed left femoral head with bone bank bone graft to fill the defect, open Autograft nerve graft to right median nerve, percutaneous endoscopic (do not code graft harvest for this exercise) Bilateral mastectomy with concomitant breast implants, open Excision of abdominal aorta with goretex graft replacement, open Total right knee arthroplasty with insertion of total knee prosthesis Abdominal wall herniorrhaphy, open, using synthetic mesh Tendon graft to right ankle using cadaver graft, open Mitral valve replacement using porcine valve, open Percutaneous phacoemulsification of right eye cataract with prosthetic lens insertion Code 0HRDX73 0QR70KZ 01R547Z 0HRV0JZ 04R00JZ 0SRC0JZ 0WRF0JZ 0LRS0KZ 02RG08Z 08RJ3JZ Procedures in the Medical and Surgical section 2.53

96 Root operations that always involve a device 12/10/07 Preliminary Change Root operation 2 Change 2 Definition Explanation Examples Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane None Urinary catheter change, gastrostomy tube change The root operation CHANGE represents only those procedures where a similar device is exchanged without making a new incision or puncture. Typical CHANGE procedures include exchange of drainage devices and feeding devices. Coding note: Change In the root operation CHANGE, general body part values are used when the specific body part value is not in the table Example: Percutaneous endoscopic gastrostomy (PEG) tube exchange Character 1 Section Character 2 GASTROINTEST. SYSTEM Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND CHANGE UPPER INTEST. EXTERNAL FEEDING NO QUALIFIER SURGICAL TRACT DEVICE 0 D 2 0 X U Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Exchange of drainage tube from right hip joint Tracheostomy tube exchange Change chest tube for left pneumothorax Exchange of cerebral ventriculostomy drainage tube Foley urinary catheter exchange Code 0S2YX0Z 0B21XFZ 0W2BX0Z 0020X0Z 0T2BX0Z This is coded to DRAINAGE DEVICE because urine is being drained ICD-10-PCS Reference Manual

97 Preliminary 12/10/07 Root operations that always involve a device Removal Root operation P Removal Definition Taking out or off a device from a body part P Explanation If taking out a device and putting in a similar device is performed with an external approach, the procedure is coded to the root operation CHANGE. Otherwise, the procedure for taking out the device is coded to the root operation REMOVAL and the procedure for putting in the new device is coded to the root operation performed. Examples Drainage tube removal, cardiac pacemaker removal REMOVAL represents a much broader range of procedures than those for removing the devices contained in the root operation INSERTION. A procedure to remove a device is coded to REMOVAL if it is not an integral part of another root operation, and regardless of the approach or the original root operation by which the device was put in. Coding note: Removal In the root operation REMOVAL, general body part values are used when the specific body part value is not in the table Example: Removal of right forearm external fixator the right upper extremity was prepped and draped in a sterile fashion. A tourniquet was placed at 250 mm of pressure. The external fixator was removed using the appropriate wrench. The four pins in the ulna were then removed manually, as well as with the drill. The wounds were irrigated with antibiotic solution and a sterile dressing applied Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND UPPER BONES REMOVAL ULNA, RIGHT EXTERNAL EXTERNAL NO QUALIFIER SURGICAL FIXATION 0 P P K X 5 Z Procedures in the Medical and Surgical section 2.55

98 Root operations that always involve a device 12/10/07 Preliminary Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Open removal of lumbar sympathetic neurostimulator Non-incisional removal of Swan-Ganz catheter from right pulmonary artery Laparotomy with removal of pancreatic drain Extubation, endotracheal tube Non-incisional PEG tube removal Transvaginal removal of extraluminal cervical cerclage Incision with removal of K-wire fixation, right first metatarsal Cystoscopy with retrieval of left ureteral stent Removal of nasogastric drainage tube for decompression Removal of external fixator, left radial fracture Code 01PY0MZ 02PYX2Z 0FPG00Z 0BP1XEZ 0DP6XUZ 0UPD7CZ 0QPN04Z 0TP98DZ 0DP6X0Z 0PPJX5Z 2.56 ICD-10-PCS Reference Manual

99 Preliminary 12/10/07 Root operations that always involve a device Revision Root operation W Revision Definition Correcting, to the extent possible, a malfunctioning or displaced device W Explanation Revision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw or pin. Examples Adjustment of pacemaker lead, adjustment of hip prosthesis REVISION is coded when the objective of the procedure is to correct the positioning or function of a previously placed device. A complete re-do of the original root operation is coded to the root operation performed. Coding note: Revision In the root operation REVISION, general body part values are used when the specific body part value is not in the table Example: Revision of artificial anal sphincter Proceeding through a suprapubic incision, this was then extended after injecting local anesthetic, thereby exposing the underlying tubing, which was then delivered through the suprapubic region. Meticulous hemostasis was achieved using electrocautery. At that point the pump device was then repositioned in the left lower quadrant abdominal wall region. The tubing was reinserted using dilators, and the skin reapproximated using 2-0 Vicryl sutures. Sterile dressing was then applied Character 1 Section Character 2 GASTROINTEST. SYSTEM Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND REVISION ANUS OPEN ARTIFICIAL NO QUALIFIER SURGICAL SPHINCTER 0 D W Q 0 L Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Reposition of Swan-Ganz catheter in superior vena cava Open revision of right hip replacement, with readjustment of prosthesis Adjustment of position, pacemaker lead in left ventricle, percutaneous External repositioning of foley catheter to bladder Revision of VAD reservoir placement in chest wall, causing patient discomfort, open Code 02WYX2Z 0SW90JZ 02WA3MZ 0TWBX0Z 0JWT0WZ Procedures in the Medical and Surgical section 2.57

100 12/10/07 Preliminary Root operations involving examination only The table below lists the root operations that involve examination of a body part. Each is described in detail in the pages that follow. Root operation Objective of procedure Site of procedure Example Inspection Visual/manual exploration Some/all of a body part Diagnostic cystoscopy Map Location electrical impulses/ functional areas Brain/cardiac conduction mechanism Cardiac electrophysiological study 2.58 ICD-10-PCS Reference Manual

101 Preliminary 12/10/07 Root operations involving examination only Inspection Root operation J Inspection Definition Visually and/or manually exploring a body part J Explanation Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers. Examples Diagnostic arthroscopy, exploratory laparotomy Example: Diagnostic colposcopy with examination of cervix The root operation INSPECTION represents procedures where the sole objective is to examine a body part. Procedures that are discontinued without any other root operation being performed are also coded to INSPECTION. Colposcopy was done which revealed pseudo-white areas at 2 o clock and 6 o clock on the cervix, with abnormal cells and irregular white borders noted on both Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND FEMALE INSPECTION CERVIX VIA NAT./ARTIF. NO DEVICE NO QUALIFIER SURGICAL REPRODUCTIVE OPENING ENDO 0 U J C 8 Z Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Thoracotomy with exploration of right pleural cavity Diagnostic laryngoscopy Exploratory arthrotomy of left knee Colposcopy with diagnostic hysteroscopy Digital rectal exam Diagnostic arthroscopy of right shoulder Endoscopy of bilateral maxillary sinus Laparotomy with palpation of liver Transurethral diagnostic cystoscopy Colonoscopy, abandoned at sigmoid colon Code 0WJ90ZZ 0CJS8ZZ 0SJD0ZZ 0UJ98ZZ 0DJP7ZZ 0RJJ4ZZ 09JQ4ZZ, 09JR4ZZ 0FJ00ZZ 0TJB8ZZ 0DJN8ZZ Procedures in the Medical and Surgical section 2.59

102 Root operations involving examination only 12/10/07 Preliminary Map Root operation K Map K Definition Explanation Examples Locating the route of passage of electrical impulses and/or locating functional areas in a body part Applicable only to the cardiac conduction mechanism and the central nervous system Cardiac mapping, cortical mapping MAPPING represents a very narrow range of procedures. Procedures include only cardiac mapping and cortical mapping. Example: Cardiac mapping under sterile technique arterial sheath was placed in the right femoral artery. The electrical catheter was advanced up the aorta and into the left atrium under fluoroscopic guidance and mapping commenced. After adequate recordings were obtained the catheter was withdrawn and hemostasis achieved with manual pressure on the right femoral artery Character 1 Section Character 2 HEART AND GR. VESSELS Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND MAP CONDUCTION PERCUTANEOUS NO DEVICE NO QUALIFIER SURGICAL MECHANISM 0 2 K 8 3 Z Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Percutaneous mapping of basal ganglia Heart catheterization with cardiac mapping Intraoperative whole brain mapping via craniotomy Mapping of left cerebral hemisphere, percutaneous endoscopic Intraoperative cardiac mapping during open heart surgery Code 00K83ZZ 02K83ZZ 00K00ZZ 00K74ZZ 02K80ZZ 2.60 ICD-10-PCS Reference Manual

103 Preliminary 12/10/07 Root operations that define other repairs The table below lists the root operations that define other repairs. CONTROL describes the effort to locate and stop postprocedural hemorrhage. REPAIR is described in detail in the pages that follow. Root operation Objective of procedure Site of procedure Example Control Stopping/attempting to stop postprocedural bleed Anatomical region Post-prostatectomy bleeding control Repair Restoring body part to its normal structure Some/all of a body part Suture laceration Procedures in the Medical and Surgical section 2.61

104 Root operations that define other repairs 12/10/07 Preliminary Control Root operation 3 Control Definition Stopping, or attempting to stop, postprocedural bleeding 3 Explanation The site of the bleeding is coded as an anatomical region and not to a specific body part. Examples Control of post-prostatectomy hemorrhage, control of post-tonsillectomy hemorrhage CONTROL is used to represent a small range of procedures performed to treat postprocedural bleeding. If performing BYPASS, DETACHMENT, EXCISION, EXTRACTION, REPOSITION, REPLACEMENT, or RESECTION is required to stop the bleeding, then CONTROL is not coded separately. Coding note: Control CONTROL includes irrigation or evacuation of hematoma done at the operative site. Both irrigation and evacuation may be necessary to clear the operative field and effectively stop the bleeding. Example: Re-opening of laparotomy site with ligation of arterial bleeder Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND ANATOMICAL CONTROL PERITONEAL OPEN NO DEVICE NO QUALIFIER SURGICAL REGIONS, GEN. CAVITY 0 W 3 G 0 Z Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Hysteroscopy with cautery of post-hysterectomy oozing and evacuation of clot Open exploration and ligation of post-op arterial bleeder, left forearm Control of post-operative retroperitoneal bleeding via laparotomy Reopening of thoracotomy site with drainage and control of post-op hemopericardium Arthroscopy with drainage of hemarthrosis at previous operative site, right knee Code 0W3R8ZZ 0X3F0ZZ 0W3H0ZZ 0W3C0ZZ 0Y3F4ZZ 2.62 ICD-10-PCS Reference Manual

105 Preliminary 12/10/07 Root operations that define other repairs Repair Root operation Q Repair Definition Restoring, to the extent possible, a body part to its normal anatomic structure and function Q Explanation Used only when the method to accomplish the repair is not one of the other root operations Examples Herniorrhaphy, suture of laceration Example: Left open inguinal herniorrhaphy The root operation REPAIR represents a broad range of procedures for restoring the anatomic structure of a body part such as suture of lacerations. REPAIR also functions as the not elsewhere classified (NEC) root operation, to be used when the procedure performed does not meet the definition of one of the other root operations. Fixation devices are included for procedures to repair the bones and joints. an incision in the left groin extending on the skin from the internal to the external inguinal ring was made. The external oblique aponeurosis was exposed. The hernia sac was then ligated at the internal ring with non-dissolving sutures. A hernia repair was then performed. The internal oblique fascia was sutured in interrupted stitches to the ilio-pubic fascia. The spermatic cord was then returned to its anatomical position. The external oblique aponeurosis was then repaired in interrupted sutures. Complete hemostasis was obtained, and the skin closed Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND LOWER REPAIR INGUINAL OPEN NO DEVICE NO QUALIFIER SURGICAL EXTREMITIES REGION, LEFT 0 Y Q 6 0 Z Z Procedures in the Medical and Surgical section 2.63

106 Root operations that define other repairs 12/10/07 Preliminary Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Suture repair of left radial nerve laceration Laparotomy with suture repair of blunt force duodenal laceration Perineoplasty with repair of old obstetric laceration, open Suture repair of right biceps tendon laceration, open Closure of abdominal wall stab wound Code 01Q60ZZ The approach value is OPEN, though the surgical exposure may have been created by the wound itself. 0DQ90ZZ 0WQN0ZZ 0LQ30ZZ 0WQF0ZZ 2.64 ICD-10-PCS Reference Manual

107 Preliminary 12/10/07 Root operations that define other objectives The last three root operations in the MEDICAL AND SURGICAL section, FUSION, ALTERATION, and CREATION, describe procedures performed for three distinct reasons. Beyond that they have little in common. A FUSION procedure puts a dysfunctional joint out of service rather than restoring function to the joint. ALTERATION encompasses a whole range of procedures that share only the fact that they are done to improve the way the patient looks. CRE- ATION represents only two very specific sex change operations. Root operation Objective of procedure Site of procedure Example Fusion Rendering joint immobile Joint Spinal fusion Alteration Modifying body part for cosmetic Some/all of a body part Face lift purposes without affecting function Creation Making new structure for sex change operation Perineum Artificial vagina/penis Procedures in the Medical and Surgical section 2.65

108 Root operations that define other objectives 12/10/07 Preliminary Fusion Root operation G Fusion G Definition Explanation Examples Joining together portions of an articular body part rendering the articular body part immobile The body part is joined together by fixation device, bone graft, or other means. Spinal fusion, ankle arthrodesis A limited range of procedures is represented in the root operation FUSION, because fusion procedures are by definition only performed on the joints. values are used to specify whether a vertebral joint fusion is anterior or posterior. Example: Anterior cervical fusion C-2 through C-4 with bone bank graft after skull tong traction was applied, incision was made in the left neck, and Gardner retractors placed to separate the intervertebral muscles at the C-2 through C-4 levels. Using the drill, a trough was incised on the anterior surface of the C-2 vertebra, and the C-2/C-3 space evacuated with a rongeur, and the accompanying cartilage removed. This procedure was then repeated at the C-3/C-4 level. Bone bank patella strut graft was trimmed with a saw and fashioned to fit the C-2/C-3 interspace. After adequate adjustments in the size and shape had been made, the graft was tapped securely into place. The procedure was repeated for the C-3/C-4 level. X-rays revealed good alignment and final position. Traction was gradually decreased to maintain position. Retractors were removed and the fascia was reapproximated with 0 Vicryl Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND UPPER JOINTS FUSION CERVICAL OPEN NONAUTOLOG ANTERIOR SURGICAL VERTEB JT, 2-6 TISSUE SUBST 0 R G 2 0 K ICD-10-PCS Reference Manual

109 Preliminary 12/10/07 Root operations that define other objectives Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Radiocarpal fusion of left hand with internal fixation, open Posterior spinal fusion at L1-L3 level with BAK cage interbody fusion device, open Intercarpal fusion of right hand with bone bank bone graft, open Sacrococcygeal fusion with bone graft from same operative site, open Interphalangeal fusion of left great toe, percutaneous pin fixation Code 0RGP04Z 0SG1041 0RGQ0KZ 0SG507Z 0SGQ34Z Procedures in the Medical and Surgical section 2.67

110 Root operations that define other objectives 12/10/07 Preliminary Alteration Root operation 0 Alteration 0 Definition Explanation Examples Modifying the natural anatomic structure of a body part without affecting the function of the body part Principal purpose is to improve appearance Face lift, breast augmentation ALTERATION is coded for all procedures performed solely to improve appearance. All methods, approaches, and devices used for the objective of improving appearance are coded here. Coding note: Alteration Because some surgical procedures can be performed for either medical or cosmetic purposes, coding for ALTERATION requires diagnostic confirmation that the surgery is in fact performed to improve appearance. Example: Cosmetic blepharoplasty attention was turned to the redundant upper eyelid skin. The ellipse of skin as marked preoperatively was excised bilaterally. The medial and lateral fat compartments were open bilaterally. The medial compartment had severe fatty excess and periorbital fat herniation. This was resected. The lateral fat compartment was opened and the lateral fat tailored as well. Subdermal closure was performed with interrupted 3-0 sutures bilaterally. The skin was closed Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND EYE ALTERATION UPPER EYELID, OPEN NO DEVICE NO QUALIFIER SURGICAL LEFT P 0 Z Z Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND EYE ALTERATION UPPER EYELID, OPEN NO DEVICE NO QUALIFIER SURGICAL RIGHT N 0 Z Z 2.68 ICD-10-PCS Reference Manual

111 Preliminary 12/10/07 Root operations that define other objectives Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Cosmetic face lift, open, no other information available Bilateral breast augmentation with silicone implants, open Cosmetic rhinoplasty with septal reduction and tip elevation using local tissue graft, open Abdominoplasty (tummy tuck), open Liposuction of bilateral thighs Code 0W020ZZ 0H0V0JZ 090K07Z 0W0F0ZZ 0J0L3ZZ, 0J0M3ZZ Procedures in the Medical and Surgical section 2.69

112 Root operations that define other objectives 12/10/07 Preliminary Creation Root operation 4 Creation Definition Making a new structure that does not physically take the place of a body part 4 Explanation Used only for sex change operations where genitalia are made Examples Creation of vagina in a male, creation of penis in a female CREATION is used to represent a very narrow range of procedures. Only the procedures performed for sex change operations are included here. Coding note: Harvesting autograft tissue If a separate procedure is performed to harvest autograft tissue, it is coded to the appropriate root operation in addition to the primary procedure. Example: Creating a vagina in a male patient using autograft Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 MEDICAL AND SURGICAL ANATOMICAL REGIONS, GEN. CREATION PERINEUM, MALE OPEN AUTOLOG. TISSUE SUBST. VAGINA 0 W 4 M Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Creation of penis in female patient using tissue bank donor graft Creation of vagina in male patient using synthetic material Code 0W4N0K1 0W4M0J ICD-10-PCS Reference Manual

113 Preliminary 12/10/07 Root operations that define other objectives Procedures in the Medical and Surgical section 2.71

114 2.72 ICD-10-PCS Reference Manual 12/10/07 Preliminary

115 Preliminary 12/10/07 Chapter 3 3Procedures in the Medical and Surgical-related sections

116 12/10/07 Preliminary Contents Procedures in the Medical and Surgical-related sections 3.3 List of Medical and Surgical-related sections of ICD-10-PCS 3.4 Obstetrics Section Root operations 3.5 Placement Section Root operations 3.7 Administration Section Root operations 3.10 Measurement and Monitoring Section Root operations 3.12 Extracorporeal Assistance and Performance Section Root operations 3.14 Extracorporeal Therapies Section Root operations 3.16 Osteopathic Section Other Procedures Section Chiropractic Section ICD-10-PCS Reference Manual

117 Preliminary 12/10/07 Chapter 3 Procedures in the Medical and Surgical-related sections THIS CHAPTER PROVIDES reference material for procedure codes in sections 1 9 of ICD-10-PCS. These nine sections define procedures related to the MEDICAL AND SURGICAL section. Codes in these sections contain characters not previously defined, such as substance, function, and method. First, a table is provided, listing the sections in order. Following the table, reference material is provided for each section, and includes General description of the section A table listing each root operation in the section, with its corresponding definition Coding notes as needed Representative examples of procedures coded in that section, in table excerpt format, with explanatory notes as needed Coding exercises that provide example procedures and their corresponding ICD-10-PCS codes, with explanatory notes as needed Procedures in the Medical and Surgical-related sections 3.3

118 12/10/07 Preliminary List of Medical and Surgical-related sections of ICD-10-PCS Nine additional sections of ICD-10-PCS include procedures related to the MEDICAL AND SURGICAL section, such as obstetrical procedures, administration of substances, and extracorporeal procedures. Section value Description 1 Obstetrics 2 Placement 3 Administration 4 Measurement and Monitoring 5 Extracorporeal Assistance and Performance 6 Extracorporeal Therapies 7 Osteopathic 8 Other Procedures 9 Chiropractic 3.4 ICD-10-PCS Reference Manual

119 Preliminary 12/10/07 Obstetrics Section 1 The OBSTETRICS section follows the same conventions established in the MEDICAL AND SURGICAL section, with all seven characters retaining the same meaning, as shown in this example of a low forceps extraction. Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 OBSTETRICS PREGNANCY EXTRACTION PRODUCTS OF VIA NAT./ARTIF. NO DEVICE LOW FORCEPS CONCEPTION OPENING 1 0 D 0 7 Z 3 Root operations There are twelve root operations in the OBSTETRICS section. Ten of these are also found in the MEDICAL AND SURGICAL section. For the complete list of root operations and their definitions, please refer to appendix A. The two root operations unique to OBSTETRICS are defined below. Value Description Definition A Abortion Artificially terminating a pregnancy E Delivery Assisting the passage of the products of conception from the genital canal Coding note: Abortion ABORTION is subdivided according to whether an additional device such as a laminaria or abortifacient is used, or whether the abortion was performed by mechanical means. If either a laminaria or abortifacient is used, then the approach is VIA NATURAL OR ARTIFICIAL OPENING. All other abortion procedures are those done by mechanical means (the products of conception are physically removed using instrumentation), and the device value is Z, NO DEVICE. Procedures in the Medical and Surgical-related sections 3.5

120 Obstetrics Section 1 12/10/07 Preliminary Example: Transvaginal abortion using vacuum aspiration technique Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part Character 5 Approach Character 6 Device Character 7 OBSTETRICS PREGNANCY ABORTION PRODUCTS OF VIA NAT./ARTIF. NO DEVICE NO QUALIFIER CONCEPTION OPENING 1 0 A 0 7 Z Z Coding note: Delivery DELIVERY applies only to manually-assisted, vaginal delivery and is defined as assisting the passage of the products of conception from the genital canal. Cesarean deliveries are coded in this section to the root operation EXTRACTION. Example: Manually-assisted delivery Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Part OBSTETRICS PREGNANCY DELIVERY PRODUCTS OF CONCEPTION Character 5 Approach Character 6 Device Character 7 EXTERNAL NO DEVICE NO QUALIFIER 1 0 E 0 X Z Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Abortion by dilation and evacuation following laminaria insertion Manually assisted spontaneous abortion Abortion by abortifacient insertion Bimanual pregnancy examination Extraperitoneal c-section, low transverse incision Fetal spinal tap, percutaneous Fetal kidney transplant, laparoscopic Code 10A07ZW 10E0XZZ Since the pregnancy was not artificially terminated, this is coded to DELIVERY, because it captures the procedure objective. The fact that it was an abortion will be identified in the diagnosis code. 10A07ZX 10J07ZZ 10D00Z ZA 10Y04ZS Open in utero repair of congenital diaphragmatic hernia 10Q00ZK Diaphragm is classified to the RESPIRATORY body system in the MEDICAL AND SURGICAL section. Laparoscopy with total excision of tubal pregnancy 10T24ZZ Transvaginal removal of fetal monitoring electrode 10P073Z 3.6 ICD-10-PCS Reference Manual

121 Preliminary 12/10/07 Placement Section 2 The PLACEMENT section follows the same conventions established in the MEDICAL AND SURGICAL section, with all seven characters retaining the same meaning, as in the example of cast change on the right forearm below. Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Region LOWER ARM, RIGHT Character 5 Approach Character 6 Device Character 7 PLACEMENT ANATOMICAL CHANGE EXTERNAL CAST NO QUALIFIER REGIONS 2 W 0 C X 2 Z Root operations The root operations in the PLACEMENT section include only those procedures performed without making an incision or a puncture. Value Description Definition 0 Change Taking out or off a device from a body region and putting back an identical or similar device in or on the same body region without cutting or puncturing the skin or a mucous membrane 1 Compression Putting pressure on a body region 2 Dressing Putting material on a body region for protection 3 Immobilization Limiting or preventing motion of a body region 4 Packing Putting material in a body region 5 Removal Taking out or off a device from a body region 6 Traction Exerting a pulling force on a body region in a distal direction Procedures in the Medical and Surgical-related sections 3.7

122 Placement Section 2 12/10/07 Preliminary Example: Change of vaginal packing Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Region Character 5 Approach Character 6 Device Character 7 PLACEMENT ANATOMICAL CHANGE FEMALE EXTERNAL PACKING NO QUALIFIER ORIFICES GENITAL TRACT MATERIAL 2 Y 0 4 X 5 Z Example: Placement of pressure dressing on abdominal wall Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Region Character 5 Approach Character 6 Device Character 7 PLACEMENT ANATOMICAL COMPRESSION ABDOMINAL EXTERNAL PRESSURE NO QUALIFIER REGIONS WALL DRESSING 2 W 1 3 X 6 Z Example: Application of sterile dressing to head wound Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Region Character 5 Approach Character 6 Device Character 7 PLACEMENT ANATOMICAL DRESSING HEAD EXTERNAL BANDAGE NO QUALIFIER REGIONS 2 W 2 0 X 4 Z Coding note: Immobilization The procedures to fit a device, such as splints and braces, as described in F0DZ6EZ and F0DZ7EZ, apply only to the rehabilitation setting. Splints and braces placed in other inpatient settings are coded to IMMOBILIZATION, table 2X3 in the PLACEMENT section. Example: Placement of splint on left finger Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Region Character 5 Approach Character 6 Device Character 7 PLACEMENT ANATOMICAL IMMOBILIZATION FINGER, LEFT EXTERNAL SPLINT NO QUALIFIER REGIONS 2 W 3 K X 1 Z Example: Placement of nasal packing Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Region Character 5 Approach Character 6 Device Character 7 PLACEMENT ANATOMICAL PACKING NASAL EXTERNAL PACKING NO QUALIFIER ORIFICES MATERIAL 2 Y 4 1 X 5 Z 3.8 ICD-10-PCS Reference Manual

123 Preliminary 12/10/07 Placement Section 2 Example: Removal of stereotactic head frame Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Region Character 5 Approach Character 6 Device Character 7 PLACEMENT ANATOMICAL REMOVAL HEAD EXTERNAL STEREOTACTIC NO QUALIFIER REGIONS APPARATUS 2 W 5 0 X 8 Z Coding note: Traction TRACTION in this section includes only the task performed using a mechanical traction apparatus. Manual traction performed by a physical therapist is coded to MANUAL THERAPY TECHNIQUES in section F, PHYSICAL REHABILITATION AND DIAGNOSTIC AUDIOLOGY (see page 4.13). Example: Lumbar traction using motorized split-traction table Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Region Character 5 Approach Character 6 Device Character 7 PLACEMENT ANATOMICAL TRACTION BACK EXTERNAL TRACTION NO QUALIFIER REGIONS APPARATUS 2 W 6 5 X 0 Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Placement of packing material, right ear Mechanical traction of entire left leg Removal of splint, right shoulder Placement of neck brace Change of vaginal packing Packing of wound, chest wall Sterile dressing placement to left groin region Removal of packing material from pharynx Placement of intermittent pneumatic compression device, covering entire right arm Exchange of pressure dressing to left thigh Code 2Y42X5Z 2W6MX0Z 2W5AX1Z 2W32X3Z 2Y04X5Z 2W44X5Z 2W27X4Z 2Y50X5Z 2W18X7Z 2W0PX6Z Procedures in the Medical and Surgical-related sections 3.9

124 12/10/07 Preliminary Administration Section 3 The ADMINISTRATION section includes infusions, injections, and transfusions, as well as other related procedures, such as irrigation and tattooing. All codes in this section define procedures where a diagnostic or therapeutic substance is given to the patient, as in the platelet transfusion example below. Character 1 Section Character 2 Character 3 Root Operation Character 4 Character 5 Approach Character 6 Substance Character 7 ADMINISTRATION CIRCULATORY TRANSFUSION CENTRAL VEIN PERCUTANEOUS PLATELETS NONAUTO- LOGOUS R 1 Root operations Root operations in this section are classified according to the broad category of substance administered. If the substance given is a blood product or a cleansing substance, then the procedure is coded to TRANSFUSION and IRRIGATION respectively. All the other substances administered, such as anti-neoplastic substances, are coded to the root operation INTRODUCTION. Value Description Definition 0 Introduction Putting in or on a therapeutic, diagnostic, nutritional, physiological, or prophylactic substance except blood or blood products 1 Irrigation Putting in or on a cleansing substance 2 Transfusion Putting in blood or blood products Example: Nerve block injection to median nerve Character 1 Section Character 2 PHYS. SYS. & ANAT. REGIONS Character 3 Root Operation Character 4 Character 5 Approach Character 6 Substance Character 7 ADMINISTRATION INTRODUCTION PERIPHERAL PERCUTANEOUS REGIONAL NO QUALIFIER NERVES ANESTHETIC 3 E 0 T 3 C Z 3.10 ICD-10-PCS Reference Manual

125 Preliminary 12/10/07 Administration Section 3 Example: Flushing of eye Character 1 Section Character 2 PHYS. SYS. & ANAT. REGIONS Character 3 Root Operation Character 4 Character 5 Approach Character 6 Substance Character 7 ADMINISTRATION IRRIGATION EYE EXTERNAL IRRIGATING NO QUALIFIER SUBSTANCE 3 E 1 C X 8 Z Example: Transfusion of cell saver red cells into central venous line Character 1 Section Character 2 Character 3 Root Operation Character 4 Character 5 Approach Character 6 Substance Character 7 ADMINISTRATION CIRCULATORY TRANSFUSION CENTRAL VEIN PERCUTANEOUS RED BLOOD AUTOLOGOUS CELLS N 0 Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Peritoneal dialysis via indwelling catheter Transvaginal artificial insemination Infusion of total parenteral nutrition via central venous catheter Esophagogastroscopy with botox injection into esophageal sphincter Percutaneous irrigation of knee joint Epidural injection of mixed steroid and local anesthetic for pain control Chemical pleurodesis using injection of tetracycline Transfusion of antihemophilic factor, (nonautologous) via arterial central line Transabdominal in-vitro fertilization, implantation of donor ovum Autologous bone marrow transplant via central venous line Code 3E1M39Z 3E0P7LZ 3E0436Z 3E0G8GC Botulinum toxin is a paralyzing agent with temporary effects; it does not sclerose or destroy the nerve. 3E1U38Z 3E0S33Z This is coded to the substance value ANTI-INFLAMMATORY. The anesthetic is only added to lessen the pain of the injection. 3E0L3TZ 30263V1 3E0P3Q G0 Procedures in the Medical and Surgical-related sections 3.11

126 12/10/07 Preliminary Measurement and Monitoring Section 4 There are two root operations in this section, and they differ in only one respect: MEASUREMENT defines one procedure and MONITORING defines a series of procedures. Root operations MEASUREMENT describes a single level taken, while MONITORING describes a series of levels obtained at intervals. For example, A single temperature reading is considered MEASUREMENT. Temperature taken every half hour for 8 hours is considered MONITORING. Instead of defining a device, the sixth character defines the physiological or physical function being tested. Value Description Definition 0 Measurement Determining the level of a physiological or physical function at a point in time 1 Monitoring Determining the level of a physiological or physical function repetitively over a period of time Example: External electrocardiogram (EKG), single reading Character 1 Section Character 2 Character 3 Root Operation Character 4 Character 5 Approach Character 6 Function Character 7 MEASUREMENT PHYSIOLOGICAL MEASUREMENT CARDIAC EXTERNAL ELECTRICAL NO QUALIFIER & MONITORING SYSTEMS ACTIVITY 4 A 0 2 X 4 Z Example: Urinary pressure monitoring Character 1 Section Character 2 Character 3 Root Operation Character 4 Character 5 Approach Character 6 Device Character 7 MEASUREMENT PHYSIOLOGICAL MONITORING URINARY VIA NAT./ARTIF. PRESSURE NO QUALIFIER & MONITORING SYSTEMS OPENING 4 A 1 D 7 B Z 3.12 ICD-10-PCS Reference Manual

127 Preliminary 12/10/07 Measurement and Monitoring Section 4 Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Cardiac stress test, single measurement EGD with biliary flow measurement Temperature monitoring, rectal Peripheral venous pulse, external, single measurement Holter monitoring Respiratory rate, external, single measurement Fetal heart rate monitoring, transvaginal Visual mobility test, single measurement Pulmonary artery wedge pressure monitoring from Swan-Ganz catheter Olfactory acuity test, single measurement Code 4A02XM4 4A0C85Z 4A1G7KZ 4A04XJ1 4A12X45 4A09XCZ 4A1H7CZ 4A07X7Z 4A133B3 4A08X0Z Procedures in the Medical and Surgical-related sections 3.13

128 12/10/07 Preliminary Extracorporeal Assistance and Performance Section 5 This section includes procedures performed in a critical care setting, such as mechanical ventilation and cardioversion. It also includes other procedures, such as hemodialysis and hyperbaric oxygen treatment. These procedures all use equipment to support a physiological function in some way, whether it is breathing, circulating the blood, or restoring the natural rhythm of the heart. The fifth and sixth characters in this section define duration and function respectively. These characters describe the duration of the procedure and the body function being acted upon, rather than the approach and device used. Root operations ASSISTANCE and PERFORMANCE are two variations of the same kinds of procedures, varying only in the degree of control exercised over the physiological function. Value Description Definition 0 Assistance Taking over a portion of a physiological function by extracorporeal means 1 Performance Completely taking over a physiological function by extracorporeal means 2 Restoration Returning, or attempting to return, a physiological function to its original state by extracorporeal means Coding note: Assistance ASSISTANCE defines procedures that support a physiological function but do not take complete control of it, such as intra-aortic balloon pump to support cardiac output and hyperbaric oxygen treatment. Example: Hyperbaric oxygenation of wound Character 1 Section EXTRACORP. ASSISTANCE & PERFORMANCE Character 2 PHYSIOLOGICAL SYSTEMS Character 3 Root Operation Character 4 Character 5 Duration Character 6 Function Character 7 ASSISTANCE CIRCULATORY INTERMITTENT OXYGENATION HYPERBARIC 5 A ICD-10-PCS Reference Manual

129 Preliminary 12/10/07 Extracorporeal Assistance and Performance Section 5 Coding note: Performance PERFORMANCE defines procedures where complete control is exercised over a physiological function, such as total mechanical ventilation, cardiac pacing, and cardiopulmonary bypass. Example: Cardiopulmonary bypass in conjunction with CABG Character 1 Section EXTRACORP. ASSISTANCE & PERFORMANCE Character 2 PHYSIOLOGICAL SYSTEMS Character 3 Root Operation Character 4 Character 5 Duration Character 6 Function Character 7 PERFORMANCE CARDIAC CONTINUOUS OUTPUT NO QUALIFIER 5 A Z Coding note: Restoration RESTORATION defines only external cardioversion and defibrillation procedures. Failed cardioversion procedures are also included in the definition of RESTORATION, and are coded the same as successful procedures. Example: Attempted cardiac defibrillation, unsuccessful Character 1 Section EXTRACORP. ASSIST. AND PERFORMANCE Character 2 PHYSIOLOGICAL SYSTEMS Character 3 Root Operation Character 4 Character 5 Duration Character 6 Function Character 7 RESTORATION CARDIAC SINGLE RHYTHM NO QUALIFIER 5 A Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Intermittent mechanical ventilation Liver dialysis, single encounter Cardiac countershock with successful conversion to sinus rhythm IPPB (intermittent positive pressure breathing) for mobilization of secretions Renal dialysis, series of encounters IABP (intra-aortic balloon pump) continuous Intra-operative cardiac pacing, continuous ECMO (extracorporeal membrane oxygenation), continuous Controlled mechanical ventilation (CMV), 45 hours Pulsatile compression boot with intermittent inflation Code 5A0915Z 5A1C00Z 5A2204Z 5A0915Z 5A1D60Z 5A A1223Z 5A A1945Z 5A02115 This is coded to the function value CARDIAC OUTPUT, because the purpose of such compression devices is to return blood to the heart faster. Procedures in the Medical and Surgical-related sections 3.15

130 12/10/07 Preliminary Extracorporeal Therapies Section 6 Section 6, EXTRACORPOREAL THERAPIES, describes other extracorporeal procedures that are not defined by ASSISTANCE and PERFORMANCE in section 5 (see page 3.14). Examples are bili-lite phototherapy, apheresis, and whole body hypothermia. The second character contains a single general body system choice, PHYSIOLOGICAL SYSTEMS, as in the phototherapy example below. The sixth character is defined as a qualifier, but contains no specific qualifier values. The seventh-character qualifier identifies various blood components separated out in pheresis procedures. Character 1 Section EXTRACORP. THERAPIES Character 2 Character 3 Root Operation Character 4 Character 5 Duration Character 6 Character 7 PHYSIOLOGICAL PHOTOTHERAPY SKIN SINGLE NO QUALIFIER NO QUALIFIER SYSTEMS 6 A Z Z Root operations The meaning of each root operation is consistent with the term as used in the medical community. DECOMPRESSION and HYPER- THERMIA have a more specialized meaning. All are defined in the table below. Value Description Definition 0 Atmospheric Control Extracorporeal control of atmospheric pressure and composition 1 Decompression Extracorporeal elimination of undissolved gas from body fluids 2 Electromagnetic Therapy Extracorporeal treatment by electromagnetic rays 3 Hyperthermia Extracorporeal raising of body temperature 4 Hypothermia Extracorporeal lowering of body temperature 5 Pheresis Extracorporeal separation of blood products 3.16 ICD-10-PCS Reference Manual

131 Preliminary 12/10/07 Extracorporeal Therapies Section 6 Value Description Definition 6 Phototherapy Extracorporeal treatment by light rays 7 Ultrasound Therapy Extracorporeal treatment by ultrasound 8 Ultraviolet Light Therapy 9 Shock Wave Therapy Extracorporeal treatment by ultraviolet light Extracorporeal treatment by shock waves Coding note: Decompression DECOMPRESSION describes a single type of procedure treatment for decompression sickness (the bends) in a hyperbaric chamber. Example: Hyperbaric decompression treatment, single Character 1 Section EXTRACORP. THERAPIES Character 2 Character 3 Root Operation DECOM- PRESSION Character 4 Character 5 Duration Character 6 Character 7 PHYSIOLOGICAL CIRCULATORY SINGLE NO QUALIFIER NO QUALIFIER SYSTEMS 6 A Z Z Coding note: Hyperthermia HYPERTHERMIA is used both to treat temperature imbalance, and as an adjunct radiation treatment for cancer. When performed to treat temperature imbalance, the procedure is coded to this section. When performed for cancer treatment, whole-body hyperthermia is classified as a modality qualifier in section D, RADIATION ONCOLOGY (see page 4.11). Example: Whole body hypothermia treatment for temperature imbalance, series Character 1 Section EXTRACORP. THERAPIES Character 2 Character 3 Root Operation Character 4 Character 5 Duration Character 6 Character 7 PHYSIOLOGICAL HYPOTHERMIA WHOLE BODY MULTIPLE NO QUALIFIER NO QUALIFIER SYSTEMS 6 A 4 G 1 Z Z Coding note: Pheresis PHERESIS is used in medical practice for two main purposes: to treat diseases where too much of a blood component is produced, such as leukemia, or to remove a blood product such as platelets from a donor, for transfusion into a patient who needs them. Procedures in the Medical and Surgical-related sections 3.17

132 Extracorporeal Therapies Section 6 12/10/07 Preliminary Example: Therapeutic leukapheresis, single treatment Character 1 Section EXTRACORP. THERAPIES Character 2 Character 3 Root Operation Character 4 Character 5 Duration Character 6 Character 7 PHYSIOLOGICAL PHERESIS CIRCULATORY SINGLE NO QUALIFIER LEUKOCYTES SYSTEMS 6 A Z 1 Coding note: Phototherapy PHOTOTHERAPY to the circulatory system means exposing the blood to light rays outside the body, using a machine that recirculates the blood and returns it to the body after phototherapy. Example: Phototherapy of circulatory system, series treatment Character 1 Section EXTRACORP. THERAPIES Character 2 Character 3 Root Operation Character 4 Character 5 Duration Character 6 Character 7 PHYSIOLOGICAL PHOTOTHERAPY CIRCULATORY MULTIPLE NO QUALIFIER NO QUALIFIER SYSTEMS 6 A Z Z Example: Ultraviolet light phototherapy, series treatment Character 1 Section EXTRACORP. THERAPIES Character 2 Character 3 Root Operation UV LIGHT PHOTOTHERAPY Character 4 Character 5 Duration Character 6 Character 7 PHYSIOLOGICAL SKIN MULTIPLE NO QUALIFIER NO QUALIFIER SYSTEMS 6 A Z Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Donor thrombocytapheresis, single encounter Bili-lite UV phototherapy, series treatment Whole body hypothermia, single treatment Circulatory phototherapy, single encounter Shock wave therapy of plantar fascia, single treatment Antigen-free air conditioning, series treatment TMS (transcranial magnetic stimulation), series treatment Therapeutic ultrasound of peripheral vessels, single treatment Plasmapheresis, series treatment Extracorporeal electromagnetic stimulation (EMS) for urinary incontinence, single treatment Code 6A550Z2 6A801ZZ 6A4G0ZZ 6A650ZZ 6A930ZZ 6A0G1ZZ 6A221ZZ 6A750ZZ 6A551Z3 6A210ZZ 3.18 ICD-10-PCS Reference Manual

133 Preliminary 12/10/07 Osteopathic Section 7 Section 7, OSTEOPATHIC, is one of the smallest sections in ICD-10-PCS. There is a single body system, ANATOMICAL REGIONS, and a single root operation, TREATMENT. The sixth-character methods such as LYMPHATIC PUMP and FASCIAL RELEASE are not explicitly defined in ICD-10-PCS, and rely on the standard definitions as used in this specialty. Value Description Definition 0 Treatment Manual treatment to eliminate or alleviate somatic dysfunction and related disorders Example: Fascial release of abdomen, osteopathic treatment Character 1 Section Character 2 Character 3 Operation Character 4 Body Region Character 5 Approach Character 6 Method Character 7 OSTEOPATHIC ANATOMICAL TREATMENT ABDOMEN EXTERNAL FASCIAL NO QUALIFIER REGIONS RELEASE 7 W 0 9 X 1 Z Example: General osteopathic mobilization of legs Character 1 Section Character 2 Character 3 Operation Character 4 Body Region Character 5 Approach Character 6 Method Character 7 OSTEOPATHIC ANATOMICAL TREATMENT LOWER EXTERNAL GENERAL NO QUALIFIER REGIONS EXTREMITIES MOBILIZATION 7 W 0 6 X 2 Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedures Isotonic muscle energy treatment of right leg Low velocity-high amplitude osteopathic treatment of head Lymphatic pump osteopathic treatment of left axilla Indirect osteopathic treatment of sacrum Articulatory osteopathic treatment of cervical region Code 7W06X8Z 7W00X5Z 7W07X6Z 7W04X4Z 7W01X0Z Procedures in the Medical and Surgical-related sections 3.19

134 12/10/07 Preliminary Other Procedures Section 8 The OTHER PROCEDURES section contains codes for procedures not included in the other medical and surgical-related sections. A single root operation, OTHER PROCEDURES, is defined below. Value Description Definition 0 Other Procedures Methodologies which attempt to remediate or cure a disorder or disease Example: Acupuncture Character 1 Section Character 2 There are relatively few procedure codes in this section, for nontraditional, whole body therapies including acupuncture and meditation. There is also a code for the fertilization portion of an in-vitro fertilization procedure. Character 3 Root Operation Character 4 Body Region Character 5 Approach Character 6 Method Character 7 OTHER ANATOMICAL OTHER WHOLE BODY PERCUTANEOUS ACUPUNCTURE NO QUALIFIER PROCEDURES REGIONS PROCEDURES 8 W Z Example: Yoga therapy Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Region Character 5 Approach Character 6 Method Character 7 OTHER ANATOMICAL OTHER WHOLE BODY EXTERNAL YOGA THERAPY NO QUALIFIER PROCEDURES REGIONS PROCEDURES 8 W 0 0 X 2 Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Meditation therapy Code 8W00X3Z 3.20 ICD-10-PCS Reference Manual

135 Preliminary 12/10/07 Procedure Therapeutic massage Suture removal, abdominal wall Isolation after infectious disease exposure In-vitro fertilization, extracorporeal ovum fertilization Code 8W00X1Z 8W02X87 8W00X5Z 8W0ZX41 Procedures in the Medical and Surgical-related sections 3.21

136 12/10/07 Preliminary Chiropractic Section 9 The CHIROPRACTIC section consists of a single body system, ANATOMICAL REGIONS, and a single root operation, MANIPULATION, defined below. Value Description Definition B Manipulation Manual procedure that involves a directed thrust to move a joint past the physiological range of motion, without exceeding the anatomical limit Example: Chiropractic treatment of cervical spine, short lever specific contact Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Region Character 5 Approach Character 6 Method Character 7 CHIROPRACTIC ANATOMICAL MANIPULATION CERVICAL EXTERNAL SHORT LEVER NO QUALIFIER REGIONS SP. CONTACT 9 W B 1 X H Z Example: Non-manual chiropractic manipulation of pelvis Character 1 Section Character 2 Character 3 Root Operation Character 4 Body Region Character 5 Approach Character 6 Method Character 7 CHIROPRACTIC ANATOMICAL MANIPULATION PELVIS EXTERNAL NON-MANUAL NO QUALIFIER REGIONS 9 W B 5 X B Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Chiropractic treatment of lumbar region using long lever specific contact Chiropractic manipulation of abdominal region, indirect visceral Chiropractic extra-articular treatment of hip region Chiropractic treatment of sacrum using long and short lever specific contact Mechanically-assisted chiropractic manipulation of head Code 9WB3XGZ 9WB9XCZ 9WB6XDZ 9WB4XJZ 9WB0XKZ 3.22 ICD-10-PCS Reference Manual

137 Preliminary 12/10/07 Chiropractic Section 9 Procedures in the Medical and Surgical-related sections 3.23

138 Chiropractic Section 9 12/10/07 Preliminary 3.24 ICD-10-PCS Reference Manual

139 Preliminary 12/10/07 Chapter 4 4Procedures in the ancillary sections

140 12/10/07 Preliminary Contents Procedures in the ancillary sections 4.3 List of ancillary sections in ICD-10-PCS 4.4 Imaging Section B 4.5 Root types 4.5 Nuclear Medicine Section C 4.8 Root types 4.8 Radiation Oncology Section D 4.11 Root type 4.11 Physical Rehabilitation and Diagnostic Audiology Section F 4.13 Root types 4.13 Mental Health Section G 4.17 Root Type 4.17 Substance Abuse Treatment Section H 4.19 Root Types ICD-10-PCS Reference Manual

141 Preliminary 12/10/07 Chapter 4 Procedures in the ancillary sections THIS CHAPTER PROVIDES reference material for procedure codes in the six ancillary sections of ICD-10-PCS (B D, F H). Codes in these sections contain characters not previously defined, such as contrast, modality qualifier and equipment. First, a table is provided, listing the sections in order. Following the table, reference material is provided for each section, and includes General description of the section A table listing each root type in the section, with its corresponding definition (sections B, C and F only) Coding notes as needed Representative examples of procedures coded in that section, in table excerpt format, with explanatory notes as needed Coding exercises that provide example procedures and their corresponding ICD-10-PCS codes, with explanatory notes as needed Procedures in the ancillary sections 4.3

142 12/10/07 Preliminary List of ancillary sections in ICD-10-PCS Six ancillary sections of ICD-10-PCS include procedures such as imaging, radiation oncology, and rehabilitation. Section value B C D F G H Description Imaging Nuclear Medicine Radiation Oncology Physical Rehabilitation and Diagnostic Audiology Mental Health Substance Abuse Treatment 4.4 ICD-10-PCS Reference Manual

143 Preliminary 12/10/07 Imaging Section B IMAGING follows the same conventions established in the MEDI- CAL AND SURGICAL section (see chapter 2), for the section, body system, and body part characters. However, the third and fourth characters introduce definitions not used in previous sections. Third character defines procedure by root type, instead of root operation. Fifth character defines contrast if used. Sixth character is a qualifier that specifies an image taken without contrast followed by one with contrast. Seventh character is a qualifier that is not specified in this section. Root types The IMAGING root types are defined in the following table. Value Description Definition 0 Plain Radiography Planar display of an image developed from the capture of external ionizing radiation on photographic or photoconductive plate 1 Fluoroscopy Single plane or bi-plane real time display of an image developed from the capture of external ionizing radiation on a fluorescent screen. The image may also be stored by either digital or analog means 2 Computerized Tomography (CT scan) 3 Magnetic Resonance Imaging (MRI) Computer reformatted digital display of multiplanar images developed from the capture of multiple exposures of external ionizing radiation Computer reformatted digital display of multiplanar images developed from the capture of radio-frequency signals emitted by nuclei in a body site excited within a magnetic field 4 Ultrasonography Real time display of images of anatomy or flow information developed from the capture of reflected and attenuated high frequency sound waves Procedures in the ancillary sections 4.5

144 Imaging Section B 12/10/07 Preliminary Example: X-ray of right clavicle, limited study Character 1 Section Character 2 Character 3 Root Type Character 4 Body Part CLAVICLE, RIGHT Character 5 Contrast Character 6 Character 7 IMAGING NON-AXIAL PLAIN NONE NONE NONE UPPER BONES RADIOGRAPHY B P 0 4 Z Z Z Example: Fluoroscopy of renal dialysis shunt using CO2 contrast Character 1 Section Character 2 Character 3 Root Type Character 4 Body Part Character 5 Contrast Character 6 Character 7 IMAGING VEINS FLUOROSCOPY DIALYSIS OTHER NONE NONE SHUNT/FISTULA CONTRAST B 5 1 W Y Z Z Example: CT of brain without contrast followed by high osmolar contrast Character 1 Section Character 2 Character 3 Root Type Character 4 Body Part Character 5 Contrast Character 6 Character 7 IMAGING CENTRAL COMPUTERIZED BRAIN HIGH OSMOLAR UNENHANCED NONE NERVOUS TOMOGRAPHY AND ENHANCED B Z Example: MRI of liver using Gadoteridol Character 1 Section Character 2 Character 3 Root Type Character 4 Body Part Character 5 Contrast Character 6 Character 7 IMAGING HEPATOBILIARY MAGNETIC LIVER OTHER NONE NONE & PANCREAS RESONANCE IMAGING CONTRAST B F 3 5 Y Z Z Example: Ultrasound of prostate gland Character 1 Section Character 2 Character 3 Root Type Character 4 Body Part Character 5 Contrast Character 6 Character 7 IMAGING MALE ULTRA- PROSTATE AND NONE NONE NONE REPRODUCTIVE SONOGRAPHY SEMINAL VESICLES B V 4 9 Z Z Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. 4.6 ICD-10-PCS Reference Manual

145 Preliminary 12/10/07 Imaging Section B Procedure Non-contrast CT of abdomen and pelvis Ultrasound guidance for catheter placement, left subclavian artery Chest X-ray, AP/PA and lateral views Endoluminal ultrasound of gallbladder and bile ducts MRI of thyroid gland, contrast unspecified Esophageal videofluoroscopy study with oral barium contrast Portable X-ray study of right radius/ulna shaft, standard series Routine fetal ultrasound, second trimester twin gestation CT scan of bilateral lungs, high osmolar contrast with densitometry Fluoroscopic guidance for percutaneous transluminal angioplasty (PTA) of left common femoral artery, low osmolar contrast Code BW21ZZZ B342ZZZ BW03ZZZ BF43ZZZ BG34YZZ BD11YZZ BP0JZZZ BY4DZZZ BB240ZZ B41G1ZZ Procedures in the ancillary sections 4.7

146 12/10/07 Preliminary Nuclear Medicine Section C NUCLEAR MEDICINE is organized like the IMAGING section (see page 4.5). The only significant difference is that the fifth character defines the radionuclide instead of the contrast material used in the procedure, as described below. The fifth character specifies the radionuclide, the radiation source used in the procedure. Choices are applicable for the root procedure type. The sixth and seventh characters are qualifiers, and are not specified in this section. Root types The third character classifies the procedure by root type instead of by root operation. Value Description Definition 1 Planar Nuclear Medicine Imaging 2 Tomographic (Tomo) Nuclear Medicine Imaging 3 Positron Emission Tomography (PET) 4 Nonimaging Nuclear Medicine Uptake Introduction of radioactive materials into the body for single plane display of images developed from the capture of radioactive emissions Introduction of radioactive materials into the body for three-dimensional display of images developed from the capture of radioactive emissions Introduction of radioactive materials into the body for three-dimensional display of images developed from the simultaneous capture, 180 degrees apart, of radioactive emissions Introduction of radioactive materials into the body for measurements of organ function, from the detection of radioactive emissions 4.8 ICD-10-PCS Reference Manual

147 Preliminary 12/10/07 Nuclear Medicine Section C Value Description Definition 5 Nonimaging Nuclear Medicine Probe 6 Nonimaging Nuclear medicine Assay 7 Systemic Nuclear Medicine Therapy Introduction of radioactive materials into the body for the study of distribution and fate of certain substances by the detection of radioactive emissions from an external source Introduction of radioactive materials into the body for the study of body fluids and blood elements, by the detection of radioactive emissions Introduction of unsealed radioactive materials into the body for treatment Example: Adenosine sestamibi (technetium) planar scan of heart muscle at rest Character 1 Section Character 2 Character 3 Root Type Character 4 Body Part Character 5 Radionuclide Character 6. Character 7 NUCLEAR HEART PLANAR MYOCARDIUM TECHNETIUM NONE NONE MEDICINE NUCLEAR IMAGING 99M C 2 1 G 1 Z Z Example: Technetium tomo scan of liver Character 1 Section Character 2 Character 3 Root Type Character 4 Body Part Character 5 Radionuclide Character 6. Character 7 NUCLEAR HEPATOBILIARY TOMO NUCLEAR LIVER TECHNETIUM NONE NONE MEDICINE AND PANCREAS IMAGING 99M C F Z Z Procedures in the ancillary sections 4.9

148 Nuclear Medicine Section C 12/10/07 Preliminary Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Tomo scan of right and left heart, unspecified radiopharmaceutical, qualitative gated rest Technetium pentetate assay of kidneys, ureters, and bladder Uniplanar scan of spine using technetium oxidronate, with first pass study Thallous chloride tomographic scan of bilateral breasts PET scan of myocardium using rubidium Gallium citrate scan of head and neck, single plane imaging Xenon gas nonimaging probe of brain Upper GI scan, radiopharmaceutical unspecified, for gastric emptying Carbon 11 PET scan of brain with quantification Iodinated albumin nuclear medicine assay, blood plasma volume study Code C226YZZ CT631ZZ CP151ZZ CH22SZZ C23GQZZ CW1BLZZ C050VZZ CD15YZZ C030BZZ C763HZZ 4.10 ICD-10-PCS Reference Manual

149 Preliminary 12/10/07 Radiation Oncology Section D RADIATION ONCOLOGY contains the radiation procedures performed for cancer treatment. Character meanings are described below. Third character defines root type, which is the basic modality. Fifth character further specifies treatment modality. Sixth character defines the radioactive isotope used, if applicable. Seventh character is a qualifier, and is not specified in this section. Root type The third character defines the treatment modality as root type. Examples are BRACHYTHERAPY and STEREOTACTIC RADIOSURGERY. Four different root types are used in this section, as listed in the table below. Value Description 0 Beam Radiation 1 Brachytherapy 2 Stereotactic Radiosurgery Y Other Radiation Example: LDR Brachytherapy of cervix using Iridium 192 Character 1 Section Character 2 Character 3 Root Type BRACHY- THERAPY Character 4 Body Part Character 5 Modal. LDR BRACHY- THERAPY Character 6 Isotope IRIDIUM 192 Character 7 RADIATION FEMALE CERVIX NONE ONCOLOGY REPRODUCTIVE D U 1 1 B 8 Z Example: Intraoperative radiation therapy (IORT) of bladder Character 1 Section Character 2 Body Sys Character 3 Root Type Character 4 Body Part Character 5 Modal. Character 6 Isotope Character 7 RADIATION URINARY OTHER BLADDER IORT NONE NONE ONCOLOGY SYSTEM RADIATION D T Y 2 C Z Z Procedures in the ancillary sections 4.11

150 Radiation Oncology Section D 12/10/07 Preliminary Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Code Plaque radiation of left eye, single port D8Y0FZZ 8 MeV photon beam radiation to brain D0011ZZ IORT of colon, 3 ports DDY5CZZ HDR Brachytherapy of prostate using Palladium 103 DV109BZ Electron radiation treatment of right breast, custom device DM013ZZ Hyperthermia oncology treatment of pelvic region DWY68ZZ Contact radiation of tongue D9Y57ZZ Heavy particle radiation treatment of pancreas, four risk sites DF034ZZ LDR brachytherapy to spinal cord using iodine D016B9Z Whole body Phosphorus 32 administration with risk to hematopoetic system DWY5GFZ 4.12 ICD-10-PCS Reference Manual

151 Preliminary 12/10/07 Physical Rehabilitation and Diagnostic Audiology Section F PHYSICAL REHABILITATION AND DIAGNOSTIC AUDIOLOGY contains character definitions unlike the other sections in ICD-10-PCS. They are described below. Second character is a section qualifier that specifies whether the procedure is a rehabilitation or diagnostic audiology procedure. Third character defines the general procedure root type. Fourth character defines the body system and body region combined, where applicable Fifth character further specifies the procedure type. Sixth character specifies the equipment used, if any. Root types This section uses the third character to classify procedures into 14 root types. They are defined in the table below. Value Description Definition 0 Speech Assessment 1 Motor and/or Nerve Function Assessment 2 Activities of Daily Living Assessment 3 Hearing Assessment 4 Hearing Aid Assessment 5 Vestibular Assessment 6 Speech Treatment Measurement of speech and related functions Measurement of motor, nerve, and related functions Measurement of functional level for activities of daily living Measurement of hearing and related functions Measurement of the appropriateness and/or effectiveness of a hearing device Measurement of the vestibular system and related functions Application of techniques to improve, augment, or compensate for speech and related functional impairment 7 Motor Treatment Exercise or activities to increase or facilitate motor function 8 Activities of Daily Living Treatment Exercise or activities to facilitate functional competence for activities of daily living Procedures in the ancillary sections 4.13

152 Physical Rehabilitation and Diagnostic Audiology Section F 12/10/07 Preliminary Value Description Definition 9 Hearing Treatment B C Hearing Aid Treatment Vestibular Treatment Application of techniques to improve, augment, or compensate for hearing and related functional impairment Application of techniques to improve the communication abilities of individuals with cochlear implant Application of techniques to improve, augment, or compensate for vestibular and related functional impairment D Device Fitting Fitting of a device designed to facilitate or support achievement of a higher level of function F Caregiver Training Training in activities to support patient s optimal level of function Coding note: Treatment Treatment procedures include swallowing dysfunction exercises, bathing and showering techniques, wound management, gait training, and a host of activities typically associated with rehabilitation. Example: Wound care treatment of left calf ulcer using pulsatile lavage Character 1 Section REHABILITATION & DIAGNOSTIC AUDIOLOGY Character 2 Section Character 3 Root Type Character 4 & Region MUSCULOSKEL. LOWER EXTREMITY Character 5 Type Character 6 Equipment Character 7 REHABILITATION ACTIVITIES OF DAILY LIVING TREATMENT WOUND MANAGEMENT PHYSICAL AGENTS NONE F 0 8 L 5 B Z Coding note: Assessment ASSESSMENTS are further classified into more than 100 different tests or methods. The majority of these focus on the faculties of hearing and speech, but others focus on various aspects of body function, and on the patient s quality of life, such as muscle performance, neuromotor development, and reintegration skills. Example: Articulation and phonology assessment using spectrograph Character 1 Section Character 2 Section Character 3 Root Type Character 4 & Region Character 5 Type Character 6 Equipment Character 7 REHABILITATION REHABILITATION SPEECH NONE ARTICULATION/ SPEECH NONE & DIAGNOSTIC AUDIOLOGY ASSESSMENT PHONOLOGY ANALYSIS F 0 0 Z 9 Q Z 4.14 ICD-10-PCS Reference Manual

153 Preliminary 12/10/07 Physical Rehabilitation and Diagnostic Audiology Section F Coding note: Device Fitting The fifth character used in DEVICE FITTING describes the device being fitted rather than the method used to fit the device. Detailed descriptions of the devices are provided in the reference materials, the table specific to DEVICE FITTING. Example: Individual fitting of moveable brace, right knee Character 1 Section Character 2 Section Character 3 Root Type Character 4 & Region Character 5 Type Character 6 Equipment Character 7 REHABILITATION REHABILITATION DEVICE FITTING NONE DYNAMIC ORTHOSIS NONE & DIAGNOSTIC AUDIOLOGY ORTHOSIS F 0 D Z 6 E Z Coding note: Caregiver Training CAREGIVER TRAINING is divided into eighteen different broad subjects taught to help a caregiver provide proper patient care. Example: Caregiver training in feeding, no special equipment used Character 1 Section Character 2 Section Character 3 Root Type Character 4 & Region Character 5 Type Character 6 Equipment Character 7 REHABILITATION REHABILITATION CAREGIVER NONE FEEDING AND NONE NONE & DIAGNOSTIC AUDIOLOGY TRAINING EATING F 0 F Z 2 Z Z Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Bekesy assessment using audiometer Individual fitting of left eye prosthesis Physical therapy for range of motion and mobility, patient right hip, no special equipment Bedside swallow assessment using assessment kit Caregiver training in airway clearance techniques Application of short arm cast in rehabilitation setting Code F13Z31Z F0DZ8UZ F07L0ZZ F00ZHYZ F0FZ8ZZ F0DZ7EZ Inhibitory cast is listed in the equipment reference table under E, ORTHOSIS. Procedures in the ancillary sections 4.15

154 Physical Rehabilitation and Diagnostic Audiology Section F 12/10/07 Preliminary Procedure Verbal assessment of patient s pain level Caregiver training in communication skills using manual communication board Group musculoskeletal balance training exercises, whole body, no special equipment Individual therapy for auditory processing using tape recorder Code F02ZFZZ F0FZJMZ Manual communication board is listed in the equipment reference table under M, AUGMENTATIVE/ ALTERNATIVE COMMUNICATION. F07M6ZZ Balance training is included in the MOTOR TREATMENT reference table under THERAPEUTIC EXERCISE. F09Z2KZ Tape recorder is listed in the equipment reference table under AUDIOVISUAL EQUIPMENT ICD-10-PCS Reference Manual

155 Preliminary 12/10/07 Mental Health Section G MENTAL HEALTH contains specific values in the third and fourth characters to describe mental health procedures. The remaining characters function as placeholders only. Character meanings are described below. Third character describes the mental health procedure root type. Fourth character further specifies the procedure type as needed. Second, fifth, sixth, and seventh characters do not convey specific information about the procedure. The value Z functions as a placeholder in these characters. Root Type The third character describes the mental health root type. There are 11 root type values in this section, as listed in the table below.. Value Description 1 Psychological Tests 2 Crisis Intervention 5 Individual Psychotherapy 6 Counseling 7 Family Psychotherapy B Electroconvulsive Therapy C Biofeedback F Hypnosis G Narcosynthesis H Group Therapy J Light Therapy Example: Galvanic skin response (GSR) biofeedback Character 1 Section Character 2 Character 3 Root Type Character 4 Type Character 5 Character 6 Character 7 MENTAL NONE BIOFEEDBACK OTHER NONE NONE NONE HEALTH BIOFEEDBACK G Z C 9 Z Z Z Procedures in the ancillary sections 4.17

156 Mental Health Section G 12/10/07 Preliminary Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Cognitive-behavioral psychotherapy, individual Narcosynthesis Light therapy ECT (Electroconvulsive therapy), unilateral, multiple seizure Crisis intervention Neuropsychological testing Hypnosis Developmental testing Vocational counseling Family psychotherapy Code GZ58ZZZ GZGZZZZ GZJZZZZ GZB1ZZZ GZ2ZZZZ GZ13ZZZ GZFZZZZ GZ10ZZZ GZ61ZZZ GZ72ZZZ 4.18 ICD-10-PCS Reference Manual

157 Preliminary 12/10/07 Substance Abuse Treatment Section H SUBSTANCE ABUSE TREATMENT is structured like a smaller version of the MENTAL HEALTH section (see page 4.17). Character meanings are described below. Third character describes the root type. Fourth character is a qualifier that further classifies the root type. Second, fifth, sixth, and seventh characters do not convey specific information about the procedure. The value Z functions as a placeholder in these characters. Root Types There are seven different root type values classified in this section, as listed in the following table. Value Description 2 Detoxification Services 3 Individual Counseling 4 Group Counseling 5 Individual Psychotherapy 6 Family Counseling 8 Medication Management 9 Pharmacotherapy Example: Pharmacotherapy treatment with Antabuse for alcohol addiction Character 1 Section SUBSTANCE ABUSE TRMNT. Character 2 NONE Character 3 Root Type PHARMACO- THERAPY Character 4 Type Character 5 Character 6 Character 7 ANTABUSE NONE NONE NONE H Z 9 3 Z Z Z Procedures in the ancillary sections 4.19

158 Substance Abuse Treatment Section H 12/10/07 Preliminary Coding exercises Using the ICD-10-PCS Tables, construct the code that accurately represents the procedure performed. Procedure Naltrexone treatment for drug dependency Substance abuse treatment family counseling Medication monitoring of patient on methadone maintenance Individual interpersonal psychotherapy for drug abuse Patient in for alcohol detoxification treatment Group motivational counseling Individual 12-step psychotherapy for substance abuse Post-test infectious disease counseling for IV drug abuser Psychodynamic psychotherapy for drug dependent patient Group cognitive-behavioral counseling for substance abuse Code HZ94ZZZ HZ63ZZZ HZ81ZZZ HZ54ZZZ HZ2ZZZZ HZ47ZZZ HZ53ZZZ HZ3CZZZ HZ5CZZZ HZ42ZZZ 4.20 ICD-10-PCS Reference Manual

159 Preliminary 12/10/07 Appendix A AICD-10-PCS definitions

160 12/10/07 Preliminary Contents ICD-10-PCS definitions A.3 Root operations A.4 Approaches A.8 A.2 ICD-10-PCS Reference Manual

161 Preliminary 12/10/07 Appendix A ICD-10-PCS definitions THIS APPENDIX CONTAINS reference tables listing the root operations and approaches used in the MEDICAL AND SURGICAL section. The first table includes the definition of each root operation, with explanation and examples. The second table includes the definition of each approach. The root operations are listed by name in alphabetical order. The approaches are listed by approach value, in numeric order followed by alphabetical order. ICD-10-PCS definitions A.3

162 12/10/07 Preliminary Root operations Alteration Definition Modifying the anatomic structure of a body part without affecting the function of the body part Explanation Principal purpose is to improve appearance Examples Face lift, breast augmentation Bypass Definition Altering the route of passage of the contents of a tubular body part Explanation Rerouting contents around an area of a body part to another distal (downstream) area in the normal route; rerouting the contents to another different but similar route and body part; or to an abnormal route and another dissimilar body part. It includes one or more concurrent anastomoses with or without the use of a device such as autografts, tissue substitutes and synthetic substitutes. Examples Coronary artery bypass, colostomy formation Change Definition Taking out or off a device from a body part and putting back an identical or similar device in or on the same body part without cutting or puncturing the skin or a mucous membrane Explanation N/A Examples Urinary catheter change, gastrostomy tube change Control Definition Stopping, or attempting to stop, postprocedural bleeding Explanation The site of the bleeding is coded as an anatomical region and not to a specific body part. Examples Control of post-prostatectomy hemorrhage, control of post-tonsillectomy hemorrhage Creation Definition Making a new structure that does not physically take the place of a body part Explanation Examples Used only for sex change operations where genitalia are made Creation of vagina in a male, creation of penis in a female Destruction Definition Eradicating all or a portion of a body part Explanation Used for the actual physical destruction of all or a portion of a body part by the direct use of energy, force or a destructive agent. None of the body part is taken out. Examples Fulguration of rectal polyp, cautery of skin lesion Detachment Definition Cutting off all or a portion of an extremity Explanation Examples Cutting off all or part of the upper or lower extremities Below knee amputation, disarticulation of shoulder Dilation Definition Expanding an orifice or the lumen of a tubular body part Explanation The orifice can be a natural orifice or an artificially created orifice. Accomplished by stretching a tubular body part using intraluminal pressure or by cutting part of the orifice or wall of the tubular body part. Examples Percutaneous transluminal angioplasty, pyloromyotomy Division Definition Separating, without taking out, a body part Explanation All or a portion of the body part is separated into two or more portions. A.4 ICD-10-PCS Reference Manual

163 Preliminary 12/10/07 Root operations Examples Spinal cordotomy, osteotomy Drainage Definition Taking or letting out fluids and/or gases from a body part Explanation Examples The qualifier DIAGNOSTIC is used to identify drainage procedures that are biopsies. Thoracentesis, incision and drainage Excision Definition Cutting out or off, without replacement, a portion of a body part Explanation Examples The qualifier DIAGNOSTIC is used to identify excision procedures that are biopsies. Partial nephrectomy, liver biopsy Extirpation Definition Taking or cutting out solid matter from a body part Explanation The solid matter may be an abnormal byproduct of a biological function or a foreign body. The solid matter is imbedded in a body part, or is in the lumen of a tubular body part. The solid matter may or may not have been previously broken into pieces. No appreciable amount of the body part is taken out. Examples Thrombectomy, choledocholithotomy Extraction Definition Pulling or stripping out or off all or a portion of a body part Explanation The body part is pulled or stripped from its location by the use of force (e.g., manual, suction). The qualifier DIAGNOSTIC is used to identify extraction procedures that are biopsies. Examples Dilation and curettage, vein stripping Fragmentation Definition Breaking solid matter in a body part into pieces Explanation The solid matter may be an abnormal byproduct of a biological function or a foreign body. Physical force (e.g., manual, ultrasonic) applied directly or indirectly through intervening body parts is used to break the solid matter into pieces. The pieces of solid matter are not taken out, but are eliminated or absorbed through normal biological functions. Examples Extracorporeal shockwave lithotripsy, transurethral lithotripsy Fusion Definition Joining together portions of an articular body part rendering the articular body part immobile Explanation The body part is joined together by fixation device, bone graft, or other means. Examples Spinal fusion, ankle arthrodesis Insertion Definition Putting in a non-biological device that monitors, assists, performs or prevents a physiological function but does not physically take the place of a body part Explanation N/A Examples Insertion of radioactive implant, insertion of central venous catheter Inspection Definition Visually and/or manually exploring a body part Explanation Visual exploration may be performed with or without optical instrumentation. Manual exploration may be performed directly or through intervening body layers. Examples Diagnostic arthroscopy, exploratory laparotomy Map Definition Locating the route of passage of electrical impulses and/or locating functional areas in a body part Explanation Applicable only to the cardiac conduction mechanism and the central nervous system Examples Cardiac mapping, cortical mapping Occlusion Definition Completely closing an orifice or the lumen of a tubular body part ICD-10-PCS definitions A.5

164 Root operations 12/10/07 Preliminary Explanation Examples The orifice can be a natural orifice or an artificially created orifice. Fallopian tube ligation, ligation of inferior vena cava Reattachment Definition Putting back in or on all or a portion of a separated body part to its normal location or other suitable location Explanation Vascular circulation and nervous pathways may or may not be reestablished. Examples Reattachment of hand, reattachment of avulsed kidney Release Definition Freeing a body part Explanation Eliminating an abnormal constraint of a body part by cutting or by use of force. Some of the restraining tissue may be taken out but none of the body part is taken out. Examples Adhesiolysis, carpal tunnel release Removal Definition Taking out or off a device from a body part Explanation If taking out a device and putting in a similar device is performed with an external approach, the procedure is coded to the root operation CHANGE. Otherwise, the procedure for taking out the device is coded to the root operation REMOVAL and the procedure for putting in the new device is coded to the root operation performed. Examples Drainage tube removal, cardiac pacemaker removal Repair Definition Restoring, to the extent possible, a body part to its normal anatomic structure and function Explanation Used only when the method to accomplish the repair is not one of the other root operations Examples Herniorrhaphy, suture of laceration Replacement Definition Putting in or on biological or synthetic material that physically takes the place of all or a portion of a body part Explanation The biological material is non-living, or the biological material is living and from the same individual. The body part may have been previously taken out, previously replaced, or may be taken out concomitantly with the Replacement procedure. If the body part has been previously replaced, a separate Removal procedure is coded for taking out the device used in the previous replacement. Examples Total hip replacement, free skin graft Reposition Definition Moving to its normal location or other suitable location all or a portion of a body part Explanation The body part is moved to a new location from an abnormal location, or from a normal location where it is not functioning correctly. The body part may or may not be cut out or off to be moved to the new location. Examples Reposition of undescended testicle, fracture reduction Resection Definition Cutting out or off, without replacement, all of a body part Explanation Examples None Total nephrectomy, total lobectomy of lung Restriction Definition Partially closing an orifice or the lumen of a tubular body part Explanation Examples The orifice can be a natural orifice or an artificially created orifice. Esophagogastric fundoplication, cervical cerclage Revision Definition Correcting, to the extent possible, a malfunctioning or displaced device A.6 ICD-10-PCS Reference Manual

165 Preliminary 12/10/07 Root operations Explanation Revision can include correcting a malfunctioning or displaced device by taking out or putting in components of the device such as a screw or pin. Examples Adjustment of pacemaker lead, adjustment of hip prosthesis Transfer Definition Moving, without taking out, all or a portion of a body part to another location to take over the function of all or a portion of a body part Explanation The body part transferred remains connected to its vascular and nervous supply. Examples Tendon transfer, skin pedicle flap transfer Transplantation Definition Explanation Examples Putting in or on all or a portion of a living body part taken from another individual or animal to physically take the place and/or function of all or a portion of a similar body part The native body part may or may not be taken out, and the transplanted body part may take over all or a portion of its function. Kidney transplant, heart transplant ICD-10-PCS definitions A.7

166 12/10/07 Preliminary Approaches Approach description Open Open Endoscopic Percutaneous Percutaneous Endoscopic Via Natural or Artificial Opening Via Natural or Artificial Opening Endoscopic Open with Percutaneous Endoscopic Assistance External Definition Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure Cutting through the skin or mucous membrane and any other body layers necessary to expose a body part, and introduction of instrumentation to reach and visualize the site of the procedure Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach the site of the procedure Entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to reach and visualize the site of the procedure Entry of instrumentation through a natural or artificial external opening to reach the site of the procedure Entry of instrumentation through a natural or artificial external opening to reach and visualize the site of the procedure Cutting through the skin or mucous membrane and any other body layers necessary to expose the site of the procedure, and entry, by puncture or minor incision, of instrumentation through the skin or mucous membrane and any other body layers necessary to aid in the performance of the procedure Procedures performed directly on the skin or mucous membrane and procedures performed indirectly by the application of external force through the skin or mucous membrane A.8 ICD-10-PCS Reference Manual

167 Preliminary 12/10/07 Appendix B BICD-10-PCS draft coding guidelines

168 12/10/07 Preliminary Contents ICD-10-PCS draft coding guidelines B.3 A. General B.3 B. Medical and Surgical section (section 0) B.4 Body system guidelines B.4 Root operation guidelines B.4 Body part guidelines B.7 Approach guidelines B.9 Device guidelines B.10 C. Other medical and surgical-related sections (sections 1 9) B.11 B.2 ICD-10-PCS Reference Manual

169 Preliminary 12/10/07 Appendix B ICD-10-PCS draft coding guidelines THIS APPENDIX LISTS the draft ICD-10-PCS guidelines. They are grouped into general guidelines and guidelines that apply to a section or sections. Guidelines for the Medical and Surgical section are further grouped by character. The guidelines are numbered sequentially within each category. A. General A.1. It is not possible to construct a procedure code from the alphabetic index. The purpose of the alphabetic index is to locate the appropriate table that contains all information necessary to construct a procedure code. A.2. All seven characters must contain valid values to be a valid procedure code. If the documentation is incomplete for coding purposes, the physician should be queried for the necessary information. A.3. The columns in the Tables contain the values for characters four through seven. The rows delineate the valid combinations of values. Any combination of values not contained in a single row of the Tables is invalid. A.4. And, when used in a code description, means and/or. Example: Lower Arm and Wrist Muscle means lower arm and/or wrist muscle. ICD-10-PCS draft coding guidelines B.3

170 12/10/07 Preliminary B. Medical and Surgical section (section 0) Body system guidelines B2.1. Body systems contain body part values that include contiguous body parts. These general body part values are used: a. When a procedure is performed on the general body part as a whole. b. When the specific body part cannot be determined. c. In the root operations Change, Removal and Revision, when the specific body part value is not in the table. Example: Esophagus is a general body part value; Esophagus, Upper is a specific body part value. B2.2. Three body systems contain body part values that represent general anatomical regions, upper extremity anatomical regions, and lower extremity anatomical regions respectively. These body part values are used when a procedure is performed on body layers that span more than one body system. Example: Debridement of skin, muscle, and bone at a procedure site is coded to the anatomical regions body systems. Exception: Composite tissue transfers are coded to the specific body systems (Muscles or Subcutaneous Tissue and Fascia). In these body systems, qualifiers delineate the body layers involved. B2.3. Body systems designated as upper or lower contain body parts located above or below the diaphragm respectively. Example: Upper Veins body parts are above the diaphragm; Lower Veins body parts are below the diaphragm. Root operation guidelines B3.1. In order to determine the appropriate root operation, the full definition of the root operation as contained in the Tables must be applied. B3.2. Components of a procedure necessary to complete the objective of the procedure specified in the root operation are considered integral to the procedure and are not coded separately. Example: Resection of a joint is integral to joint replacement. B.4 ICD-10-PCS Reference Manual

171 Preliminary 12/10/07 Multiple procedures B3.3. During the same operative episode, multiple procedures are coded if: a. The same root operation is performed on different body parts as defined by distinct values of the body part character. Example: Diagnostic excision of liver and pancreas are coded separately. b. The same root operation is repeated at different body sites that are included in the same body part value. Example: Excision of the sartorius muscle and excision of the gracilis muscle are both included in the upper leg muscle body part value, and multiple procedures are coded. Destruction of separate skin body sites on the face are all included in the body part value Skin, Face, and multiple procedures are coded. c. Multiple root operations with distinct objectives are performed on the same body part. Example: Destruction of sigmoid lesion and bypass of sigmoid colon are coded separately. d. The intended root operation is attempted using one approach, but is converted to a different approach. Example: Laparoscopic cholecystectomy converted to an open cholecystectomy is coded as endoscopic Inspection and open Resection. Discontinued procedures B3.4. If the intended procedure is discontinued, code the procedure to the root operation performed. If a procedure is discontinued before any other root operation is performed, code the root operation Inspection of the body part or anatomical region inspected. Example: Ureteroscopy with unsuccessful extirpation of ureteral stone is coded to Inspection of ureter. Bypass B3.5. Bypass procedures are coded according to the direction of flow of the contents of a tubular body part: the body part value identifies the origin of the bypass and the qualifier identifies the destination of the bypass. Example: Bypass from stomach to jejunum, stomach (origin) is the body part and jejunum (destination) is the qualifier. Note: Coronary arteries are coded differently. The body part value identifies the number of coronary artery sites bypassed. The qualifier identifies the origin of the bypass. ICD-10-PCS draft coding guidelines B.5

172 12/10/07 Preliminary B3.6. If multiple coronary artery sites are bypassed, a separate procedure is coded for each coronary artery site that uses a different device and/or qualifier. Example: Aortocoronary artery bypass and internal mammary coronary artery bypass are coded separately. Control B3.7. If an attempt to stop postprocedural bleeding is unsuccessful and requires performing Bypass, Detachment, Excision, Extraction, Reposition, Replacement, or Resection to stop the bleeding, then that root operation is coded instead of Control. Example: Resection of spleen to stop postprocedural bleeding is coded to Resection instead of Control. Diagnostic excision B3.8. If a diagnostic excision (biopsy) is followed by a therapeutic excision at the same procedure site, or by resection of the body part during the same operative episode, code only the therapeutic excision or resection. Example: Biopsy of breast followed by partial mastectomy at the same procedure site, only the partial mastectomy procedure is coded. Inspection B3.9. Inspection of a body part(s) integral to the performance of the procedure is not coded separately. Example: Fiberoptic bronchoscopy with irrigation of bronchus, only the irrigation procedure is coded. B3.10. If multiple body parts are inspected, the body part character is defined as the general body part value that identifies the entire area inspected. If no general body part value is provided, the body part character is defined as the most distal body part inspected. Example: Laparoscopy of pelvic organs is coded to the pelvic region body part value. Cystoureteroscopy with inspection of bladder and ureters is coded to the ureter body part value. Division and Release B3.11. If the sole objective of the procedure is separating a nontubular body part, the root operation is Division. If the sole objective of the procedure is freeing a body part without cutting the body part, the root operation is Release. B3.12. In the root operation Release, the body part value coded is the body part being freed and not the tissue being manipulated or cut to free the body part. Example: Lysis of intestinal adhesions is coded to one of the intestine body part values. B.6 ICD-10-PCS Reference Manual

173 Preliminary 12/10/07 Fusion of vertebral joints B3.13. If multiple vertebral joints included in the same body part value are fused, a separate procedure is coded for each joint that uses a different device and/or qualifier. Joints between two areas of the spine (e.g., cervicothoracic vertebral joint) have their own body part values and are coded separately. Example: Fusion of C-4/5 with fixation device and C-5/6 with bone graft are coded separately. Fusion of the C-5/6 joint and the C7-T1 joint are coded separately. Fracture treatment B3.14. Reduction of a displaced fracture is coded to the root operation Reposition. Treatment of a nondisplaced fracture is coded to the procedure performed. Example: Putting a pin in a nondisplaced fracture is coded to the root operation Insertion. Casting of a nondisplaced fracture is coded to the root operation Immobilization in the Placement section. Transplantation B3.15. Putting in a mature and functioning living body part taken from another individual or animal is coded to the root operation Transplantation. Putting in autologous or nonautologous cells is coded to the Administration section. Example: Putting in autologous or nonautologous bone marrow, pancreatic islet cells or stem cells is coded to the Administration section. Body part guidelines B4.1. If a procedure is performed on a portion of a body part that does not have a separate body part value, code the body part value corresponding to the whole body part. Example: A procedure performed on the alveolar process of the mandible is coded to the mandible body part. B4.2. If the prefix peri is used with a body part to identify the site of the procedure, the body part value is defined as the body part named. Example: A procedure site identified as perirenal is coded to the kidney body part. B4.3. If the procedure documentation uses a body part to further specify the site of the procedure, the body part value is defined as the body part on which the procedure is performed. Example: A procedure site identified as the prostatic urethra is coded to the urethra body part. ICD-10-PCS draft coding guidelines B.7

174 12/10/07 Preliminary Coronary arteries B4.4. The coronary arteries are classified as a single body part. They are further specified by number of sites treated, not by name or number of arteries. Separate body part values are provided to indicate the number of sites treated, when the same procedure is performed on multiple sites in the coronary arteries. Example: Two dilations with stents of a coronary artery are coded as dilation of Coronary Artery, Two Sites, with intraluminal device. Two dilations, one with stent and one without, are coded separately as dilation of Coronary Artery, One Site, with intraluminal device, and dilation of Coronary Artery, One Site, with no device. Bilateral body part values B4.5. Bilateral body part values are available for a limited number of body parts. They are included in the system on the basis of frequency and common practice. If the identical procedure is performed on contralateral body parts, and a bilateral body part value exists for that body part, a single procedure is coded using the bilateral body part value. If no bilateral body part value exists, code each procedure separately using the appropriate body part value. Example: The identical procedure performed on both fallopian tubes is coded once using the body part value Fallopian Tube, Bilateral. The identical procedure performed on both knee joints is coded twice using the body part values Knee Joint, Right and Knee Joint, Left. Body parts near a joint B4.6. Procedures performed on tendons, ligaments, bursae and fascia supporting a joint are coded to the body part that is the focus of the procedure, in the respective body system. Procedures performed on joint structures are coded to the body part in the joint body systems. Example: Repair of the anterior cruciate ligament of the knee is coded to the knee body part in the bursae and ligaments body system. Shoulder arthroscopy with shaving of articular cartilage is coded to the shoulder joint body part. B4.7. In body systems containing skin, subcutaneous tissue, muscle, and tendon body part values, where a specific body part value does not exist for the area surrounding a joint, the corresponding body part is coded as follows: Shoulder is coded to Upper Arm Elbow is coded to Lower Arm Wrist is coded to Lower Arm Hip is coded to Upper Leg Knee is coded to Lower Leg B.8 ICD-10-PCS Reference Manual

175 Preliminary 12/10/07 Ankle is coded to Foot Fingers and toes B4.8. If a body system does not contain a separate body part value for fingers, procedures performed on the fingers are coded to the body part value for the hand. If a body system does not contain a separate body part value for toes, procedures performed on the toes are coded to the body part value for the foot. Example: Excision of finger muscle is coded to the hand muscle body part value. Humerus Skin glands and ducts Forequarter and hindquarter Nerves and vessels B4.9. Procedures performed on the distal (elbow) end of the humerus are coded to the humeral shaft body part value. B4.10. Procedures performed on skin and breast glands and ducts are coded to body part values in the body system Skin and Breast. B4.11. In the anatomical regions body system containing lower extremities body parts, the body part value Forequarter describes the entire upper limb plus the scapula and clavicle, and the body part value Hindquarter describes the entire lower limb including all of the hip and the buttock. B4.12. Nerves and vessels that are not identified by a separate body part value are coded to the closest proximal branch identified by a body part value. Example: A procedure performed on the mandibular branch of the trigeminal nerve is coded to the trigeminal nerve body part value. Approach guidelines Endoscopic assistance B5.1. Procedures performed using the open approach with percutaneous endoscopic assistance are coded to approach value 0, Open. Example: Laparoscopic-assisted sigmoidectomy is coded to approach value 0, Open. B5.2. Procedures performed via natural or artificial opening with percutaneous endoscopic assistance are coded to approach value F, Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance. Example: Laparoscopic-assisted vaginal hysterectomy (LAVH) is coded to approach value F, Via Natural or Artificial Opening with Percutaneous Endoscopic Assistance. ICD-10-PCS draft coding guidelines B.9

176 12/10/07 Preliminary External approach B5.3a. Procedures performed within an orifice on structures that are visible without the aid of any instrumentation are coded to approach value X, External. Example: Resection of tonsils is coded to approach value X, External. B5.3b. Procedures performed indirectly by the application of external force through the intervening body layers are coded to approach value X, External. Example: Closed reduction of fracture is coded to approach value X, External. Indwelling device B5.4a. Procedures performed via indwelling device are coded to approach value 3, Percutaneous. Example: Fragmentation of kidney stone performed via percutaneous nephrostomy is coded to approach value 3, Percutaneous. B5.4b. Procedures performed on a device, as defined in the root operations Change, Irrigation, Removal and Revision, are coded to the procedure performed. Example: Irrigation of percutaneous nephrostomy tube is coded to the root operation Irrigation of indwelling device in the Administration section. Device guidelines B6.1. A device is coded only if a device remains after the procedure is completed. If no device remains, the device value No Device is coded. B6.2. Materials such as sutures, ligatures, radiological markers and temporary post-operative wound drains are considered integral to the performance of a procedure and are not coded as devices. B6.3. A separate procedure to put in a drainage device is coded to the root operation Drainage with the device value Drainage Device. B6.4. If, as part of a procedure, an autograft is obtained from a different body part, a separate procedure is coded. Example: Coronary bypass with excision of saphenous vein graft, excision of saphenous vein is coded separately. B.10 ICD-10-PCS Reference Manual

177 Preliminary 12/10/07 C. Other medical and surgical-related sections (sections 1 9) C.1. The Obstetrics section includes only the procedures performed on the products of conception. Procedures performed on the pregnant female other than the products of conception are coded to a root operation in the Medical and Surgical section. Example: Episiotomy is coded to a root operation in the Medical and Surgical section. ICD-10-PCS draft coding guidelines B.11

178 B.12 ICD-10-PCS Reference Manual 12/10/07 Preliminary

179 Preliminary 12/10/07 Glossary Character One of the seven components that comprise an ICD-10-PCS procedure code Value Individual units defined for each character and represented by a number or letter Procedure The complete specification of the seven characters Section (1st character) Defines the general type of procedure (2nd character) Defines the general physiological system on which the procedure is performed or anatomical region where the procedure is performed Root Operation (3rd character) Defines the objective of the procedure Body Part or Region (4th character) Defines the specific anatomical site where the procedure is performed Approach (5th character) Defines the technique used to reach the site of the procedure Glossary G.1

180 12/10/07 Preliminary Device (6th character) Defines the material or appliance that remains in or on the body at the end of the procedure (7th character) Defines an additional attribute of the procedure performed, if applicable G.2 ICD-10-PCS Reference Manual

181 Index A Abortion, 3.6 Abortion coding note, 3.5 Administration, 3.10 root operation, 3.10 introduction, 3.10 irrigation, 3.11 transfusion, 3.11 Alter a tubular body part, 2.40 Alteration coding note, 2.68 Ancillary sections, 1.12 Ancillary sections of ICD-10-PCS, list of, 4.4 Approach character, 1.8 Approach values coding note, 2.17, 2.28 Approaches definitions, A.8 Assessment coding note, 4.14 Assistance, 3.14 Assistance coding note, 3.14 Autograph tissue coding note, 2.70 B Body part character, 1.8 Body part values coding note, 2.23, 2.30 Body system character, 1.7 Bone marrow coding note, 2.9 Bypass, 2.47 C Caregiver training coding note, 4.15 Change, 2.54, 3.8 Character 1, 1.7 Character 2, 1.7 Character 3, 1.8 Character 4, 1.8 Character 5, 1.8 Character 6, 1.9 Character 7, 1.9 Character values, 1.6 Characters used in ICD-10-PCS, 1.6 Code list, 1.17 Code structure, 1.6 Code tables, 1.13 Coded data, 1.26 Coding note abortion (obstetrics), 3.5 alteration, 2.68 approach values, 2.17, 2.28 assessment, 4.14 assistance (extracorporeal assistance and performance), 3.14 body part values, 2.23, 2.30 bone marrow, 2.9 caregiver training, 4.15 control, 2.62 delivery (obstetrics), 3.6 endometrial biopsies, 2.9 fitting, 4.15 harvest autograph tissue, 2.70 Index I.1

182 hyperthermia (extracorporeal therapies), 3.17 immobilization (placement), 3.8 lymph nodes, 2.11 performance (extracorporeal assistance and performance), 3.15 pheresis (extracorporeal therapies), 3.17 phototherapy (extracorporeal therapies), 3.18 qualifier values, 2.15 restoration (extracorporeal assistance and performance), 3.15 traction (placement), 3.9 treatment, 4.14 Comparing ICD-9-CM to ICD-10-PCS, 1.4 Complete ray amputation, 2.13 Completeness, 1.19 Compression, 3.8 Control, 2.62 Control coding note, 2.62 Cutting or separation only, 2.27 D Data in healthcare, 1.26 Definition of ICD-10-PCS, 1.4 Delivery, 3.6 Delivery coding note, 3.6 Destruction, 2.16 Detachment, 2.13 qualifiers, 2.13 Device root operations always involving, 2.49 Device character, 1.9 Dilation, 2.45 Division, 2.28 Drainage, 2.21 E Endometrial biopsies coding note, 2.9 Examination only, 2.58 Excision, 2.9 Expandable system, 1.21 Extirpation, 2.23 Extracorporeal assistance and performance, 3.14 root operation, 3.14 assistance, 3.14 performance, 3.15 restoration, 3.15 Extracorporeal therapies, 3.16 root operation, 3.16 Extraction, 2.18 F Fifth character, 1.8 First character, 1.7 Fitting coding note, 4.15 Fourth character, 1.8 Fragmentation, 2.25 Function, measurement and monitoring, 3.12 Fusion, 2.66 G Glossary, G.1 H Harvest autograph tissue coding note, 2.70 History of ICD-10-PCS, 1.4 Hyperthermia coding note, 3.17 I ICD-10-PCS code list, 1.17 ICD-10-PCS defined, 1.4 ICD-10-PCS design, 1.18 ICD-10-PCS index, 1.15 ICD-10-PCS tables, 1.13 Imaging, 4.5 Immobilization, 3.8 Immobilization coding note, 3.8 Index, 1.15 Insertion, 2.50 Inspection, 2.59 Introduction, 3.10 Introduction to ICD10-PCS, 1.4 Irrigation, 3.11 L List of ancillary sections in ICD-10-PCS, 4.4 List of codes, 1.17 Lymph nodes coding note, 2.11 M Map, 2.60 Measurement, 3.12 Measurement and monitoring, 3.12 definitions of, 3.12 functions, 3.12 I.2 ICD-10-PCS Reference Manual

183 root operation, 3.12 measurement, 3.12 monitoring, 3.12 Medical and surgical list of related sections, 1.11, 3.4 root operations bypass, 2.47 change, 2.54 control, 2.62 destruction, 2.16 detachment, 2.13 dilation, 2.45 division, 2.28 drainage, 2.21 excision, 2.9 extirpation, 2.23 extraction, 2.18 fragmentation, 2.25 fusion, 2.66 insertion, 2.50 inspection, 2.59 map, 2.60 occlusion, 2.43 reattachment, 2.34 release, 2.29 removal, 2.55 repair, 2.63 replacement, 2.52 reposition, 2.38 resection, 2.11 restriction, 2.41 revision, 2.57 transfer, 2.36 transplantation, 2.32 Medical and surgical section described, 1.11 Medical and surgical subgroups, 2.6 Mental health, 4.17 Monitoring, 3.12 Move a body part, 2.31 Multiaxial design, 1.18 N New procedure codes, 1.21 Non-medically necessary procedures, 2.65 Not elsewhere classified (NEC) codes, 1.25 Not otherwise specified (NOS) codes, 1.25 Nuclear medicine, 4.8 O Obstetrics, 3.5 root operation, 3.5 abortion, 3.6 delivery, 3.6 Occlusion, 2.43 Osteopathic, 3.19 root operation, 3.19 treatment, 3.19 Other repairs, 2.61 P Packing, 3.8 Partial ray amputation, 2.13 Performance, 3.15 Performance coding note, 3.15 Pheresis coding note, 3.17 Phototherapy coding note, 3.18 Physical rehabilitation and diagnostic audiology, 4.13 Placement, 3.7 root operation, 3.7 change, 3.8 compression, 3.8 immobilization, 3.8 packing, 3.8 removal, 3.9 traction, 3.9 Procedure non-medically necessary, 2.65 substance abuse treatment, 4.19 Put in/back a body part, 2.31 Q defined, 1.9 detachment, 2.13 character, 1.9 values coding note, 2.15 R Radiation oncology, 4.11 treatment modality, 4.11 Reading codes, 1.28 Reattachment, 2.34 Related sections, 1.11 Release, 2.29 Removal, 2.55, 3.9 Remove, 2.8 Remove solid, fluids, gases from body part, 2.20 Repair, 2.63 Replacement, 2.52 Index I.3

184 Reposition, 2.38 Resection, 2.11 Restoration, 3.15 Restoration coding note, 3.15 Restriction, 2.41 Revision, 2.57 Root operation administration, 3.10 introduction, 3.10 irrigation, 3.11 transfusion, 3.11 character, 1.8 defined, 1.8 extracorporeal assistance and performance, 3.14 assistance, 3.14 performance, 3.15 restoration, 3.15 extracorporeal therapies, 3.16 measurement and monitoring, 3.12 measurement, 3.12 monitoring, 3.12 medical and surgical alter diameter or route of tubular body part, 2.40 always involve device, 2.49 bypass, 2.47 change, 2.54 control, 2.62 cutting or separation only, 2.27 destruction, 2.16 detachment, 2.13 dilation, 2.45 division, 2.28 drainage, 2.21 examination only, 2.58 excision, 2.9 extirpation, 2.23 extraction, 2.18 fragmentation, 2.25 fusion, 2.66 insertion, 2.50 inspection, 2.59 map, 2.60 non-medically necessary procedures, 2.65 occlusion, 2.43 other repairs, 2.61 put in, put back, move some or all of a body part, 2.31 reattachment, 2.34 release, 2.29 removal, 2.55 remove solid, fluids, gases from body part, 2.20 remove some or all of a body party, 2.8 repair, 2.63 replacement, 2.52 reposition, 2.38 resection, 2.11 restriction, 2.41 revision, 2.57 subgroups, 2.6 transfer, 2.36 transplantation, 2.32 obstetrics, 3.5 abortion, 3.6 delivery, 3.6 osteopathic, 3.19 treatment, 3.19 placement, 3.7 change, 3.8 compression, 3.8 immobilization, 3.8 packing, 3.8 removal, 3.9 traction, 3.9 Root operations definitions, A.4 S Search capability, 1.26 Second character, 1.7 Section administration, 3.10 ancillary, 1.12 extracorporeal assistance and performance, 3.14 extracorporeal therapies, 3.16 imaging, 4.5 list of medical and surgical sections, 3.4 measurement and monitoring, 3.12 medical and surgical-related, 1.11 mental health, 4.17 nuclear medicine, 4.8 obstetrics, 3.5 osteopathic, 3.19 physical rehabilitation and diagnostic audiology, 4.13 placement, 3.7 radiation oncology, 4.11 substance abuse treatment, 4.19 Section code, 1.7 Sections in ICD-10-PCS, 1.11 Seventh character, 1.9 Sixth character, 1.9 Standard character meanings, 1.27 Standard terminology, 1.23 Structure of codes, 1.6 Subgroups medical and surgical, 2.6 Substance abuse treatment, 4.19 procedures, 4.19 I.4 ICD-10-PCS Reference Manual

185 T Tables understanding, 1.15 Terminology used in ICD-10-PCS, 1.23 Terms, G.1 complete ray amputation, 2.13 partial ray amputation, 2.13 Third character, 1.8 Traction, 3.9 Traction coding note, 3.9 Transfer, 2.36 Transfusion, 3.11 Transplantation, 2.32 Treatment, 3.19 Treatment coding note, 4.14 Treatment modality in radiation oncology, 4.11 Tubular body part, 2.40 U Understanding ICD-10-PCS tables, 1.15 Unique codes, 1.19 Using the ICD-10-PCS index, 1.15 V Values of each character in a code, 1.6 W World Health Organization, 1.4 Index I.5

186 I.6 ICD-10-PCS Reference Manual